Gonorrhea - female

Alternative names
The clap - female

Definition
Gonorrhea is a sexually transmitted disease (commonly known as “the clap”) caused by the bacterium Neisseria gonorrhea. See also gonorrhea - male.

Causes, incidence, and risk factors

Gonorrhea is one of the most common infectious bacterial diseases and is most frequently transmitted during sexual activity, including vaginal intercourse and both oral and anal sex.

Gonorrhea is a reportable disease and all state governments require that cases of diagnosed gonorrhea be reported to the health authorities (State Board of Health). This allows for adequate follow-up and testing of sexual contacts.

There are almost 400,000 cases of gonorrhea reported to the CDC (Centers for Disease Control and Prevention) each year in the United States. There are probably many cases that are treated but not reported.

The total number of cases is thought to approach 1,000,000; if unreported cases are included, some estimates reach 2,000,000. A rate of 400,000 cases per year means that 1 out of every 687 Americans has gonorrhea. A rate of 2 million means that 1 in every 130 Americans are infected.

Gonorrhea is more common in large metropolitan areas, inner-city areas, populations with lower overall levels of education and people with lower socioeconomic status. Gonorrhea is most prevalent in people 15 to 29 years old.

Risk factors include having multiple sexual partners, having a partner with a past history of any STD, and having unprotected sex (sex without the use of a condom).

Gonorrhea is easily transmitted during oral, vaginal, or anal sex. The bacteria can infect the throat, producing a severe sore throat (gonococcal pharyngitis). It can infect the vagina, causing irritation with drainage (vaginitis), or the anus and rectum, producing a condition called proctitis.

In addition, the organisms may spread up the female reproductive tract, through the cervix and uterus, into the fallopian tubes (the tubes that carry the egg from the ovaries to the uterus).

When the infection spreads into the fallopian tubes, the infection is called PID or pelvic inflammatory disease. This occurs in 10% to 15% of women with untreated gonorrhea. If the bacteria spreads beyond the fallopian tubes, it can spread into the abdominal space and cause a severe infection, peritonitis. The bacteria can also spread to the blood stream causing gonococcemia and may settle in a joint causing gonococcal arthritis.

On rare occasions, gonorrhea can spread through non-sexual contact. An infected woman may transmit the infection to her newborn during childbirth. Infection of the newborn’s eyes is called ophthalmia neonatorum (gonococcal conjunctivitis).

Young girls who contract gonorrhea either from sexual abuse or intimate contact with recently contaminated objects (such as a damp towel) develop a severe infection called vulvovaginitis.

Approximately 50% of women with gonorrhea have no symptoms (asymptomatic). They may be completely unaware that they have contracted the disease, and subsequently do not seek treatment. This increases the risk of complications and the risk of passing the infection on to other individuals.

Symptoms of gonorrhea usually appear 2 to 5 days after infection. When women have symptoms, they often note vaginal discharge, increased urinary frequency, and urinary discomfort (dysuria). Spread of the organism to the fallopian tubes and abdomen may cause severe lower-abdominal pain and fever.

Ultimately, gonorrhea may result in scarring of the fallopian tubes and permanent sterility (inability to become pregnant). Scar tissue formation around the uterus and tubes may result in painful intercourse (dyspareunia) and chronic pelvic pain.

Gonorrhea is often associated with the presence of other sexually transmitted diseases. About half of the women with gonorrhea are also infected with chlamydia, another very common STD that can result in sterility. Women who have contracted gonorrhea should request testing for other sexually transmitted diseases including AIDS.

Symptoms

     
  • vaginal discharge  
  • pain or burning on urination  
  • urinary hesitancy  
  • sore throat  
  • painful sexual intercourse  
  • mouth sores

Signs and tests

     
  • cervical gram stain  
  • endocervical culture for gonorrhea  
  • throat swab culture  
  • skin lesion aspiration  
  • rectal culture

Gonorrhea can be identified in women most rapidly when the organisms are seen under the microscope in a sample from the cervix. Although this method is the fastest, it is not the most certain.

Cultures provide absolute proof of infection. Neisseria gonorrhea organisms may grow in any tissue of the body. They can be easily cultured from most areas using standard culture techniques.

In suspected cases of gonorrhea, cultures should be taken from the cervix, vagina, anus, urethra, or the throat (pharynx). Laboratories can give a preliminary diagnosis often within 24 hours and a confirmed diagnosis within 72 hours.

Treatment

There are two important steps to treating a sexually transmitted disease, especially one as easily spread as gonorrhea. The first is to cure the infected person. The second is to locate and test all of the person’s other sexual contacts and to treat them to prevent further spread of the disease.

That is why mandatory reporting has been instituted and has, until recently, held the number of cases of gonorrhea at a low level. However, the number of infections is once again rising.

Even though penicillin is effective against gonorrhea, there have been increasing numbers of strains that are resistant to penicillin (they don’t respond to penicillin treatment). Because of this, gonorrhea is now treated by a large number of new and very potent antibiotics. More recently, resistance to antibiotics such a ciprofloxacin, ofloxacin (or levoflaxacin), and enoxacin has become a problem.

Common prescriptions are one of the following:

     
  • ceftriaxone 125 mg injected into a muscle, one time  
  • cefixime 400 mg by mouth, one time  
  • ciprofloxacin 500 mg by mouth, one time  
  • ofloxacin 400 mg by mouth, one time  
  • cefuroxime Axotal 1 g by mouth, one time  
  • cefpodoxime proxetil 200 mg by mouth, one time  
  • enoxacin 400 mg given by mouth, one time

A follow-up visit 7 days after treatment to recheck cultures and confirm the cure of infection is important, especially for women who may not have symptoms associated with the infection.

Expectations (prognosis)
When gonorrhea is treated immediately upon onset, the outcome is likely to be good, meaning that no permanent scarring will have taken place and fertility will be maintained. When treatment is delayed there is a greater likelihood of complication and a high probability of sterility.

Complications
Untreated gonorrhea may spread to other parts of the body causing disseminated infection. The following is a list of possible complications:

     
  • salpingitis  
  • pelvic inflammatory disease  
  • peritonitis  
  • bacteremia (gonococcemia)  
  • gonococcal arthritis  
  • gonococcal pharyngitis  
  • ophthalmia neonatorum (gonococcal conjunctivitis)  
  • vulvovaginitis  
  • sterility  
  • dyspareunia

Calling your health care provider

If you have symptoms suggestive of gonorrhea, you should call your health care provider immediately. If you are short of funds or uninsured, state sponsored Sexually Transmitted Disease Clinics will diagnose and treat STDs without charge.

Using a state sponsored clinic allows the state to keep accurate statistics on the number of cases and to treat other infected contacts who would otherwise spread the disease.

Women who have engaged in high risk sexual practices (unprotected sex, multiple partners, unknown partners and so on) should be periodically examined to check for the presence of asymptomatic disease.

Prevention

Abstinence is the only absolute method of preventing gonorrhea. A monogamous sexual relationship with an individual known to be free of any STD can reduce risk. The use of condoms, both male and female types, markedly decrease the likelihood of contracting a sexually transmitted disease but they must be used properly.

The condom should be in place from the beginning to end of sexual activity and should be used every time the person engages in sexual activity with a nonmonogamous partner or other suspect partner. Condoms are inexpensive, considering the consequences of contracting a sexually transmitted disease.

Treatment of all sexual partners is essential to prevent reinfection, and is a primary reason that the government has implemented mandatory reporting. Gonorrhea is still relatively easily cured and total eradication of the disease is, in theory, at least possible as the gonorrhea organism appears to exist only on the mucous membranes of humans.

Johns Hopkins patient information

Last revised: December 3, 2012
by Gevorg A. Poghosian, Ph.D.

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