Sexually Transmitted Diseases (STDs) Diagnosis and Treatment

Common sexually transmitted diseases in women

Women are particularly affected by several sexually transmitted diseases, including:

• HIV/AIDS
• Gonorrhoea
• Chlamydia
• Pubic lice
• HPV (Human papillomavirus)
• Chancroid
• Syphilis
• Genital herpes

Recent trends in sexually transmitted diseases

The 2019 Sexually Transmitted Disease Surveillance Report from the Centers for Disease Control and Prevention (CDC) highlighted concerning trends. Cases of chlamydia, syphilis, and gonorrhoea were rising.

Notably, A particularly alarming outcome of rising syphilis cases has been the increase in congenital syphilis, where the infection is passed from mother to baby when the mother is pregnant with the child. Congenital syphilis can lead to serious health complications for the newborn, miscarriage, neonatal death, and stillbirth.

Cases of syphilis and gonorrhoea reached their highest levels since 1991. Almost 1.7 million cases of chlamydia were recorded—the highest number ever reported.

Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS)

Human immunodeficiency virus (HIV) weakens the body's immunity, making individuals more vulnerable to infections and perhaps cancer. This virus is spread primarily through sharing needles, from an infected pregnant woman to her baby or while engaging in sexual activities.

Early symptoms may mimic flu-like illnesses, including a swollen lymph node, diarrhoea, sore throat, and fever. These symptoms typically occur 14-28 days after infection but may not always be noticed.

Without treatment, the virus progresses to AIDS (acquired immunodeficiency syndrome) over an average of 10 years. AIDS is characterised by severe immune suppression, leading to weight loss, infections, cancers, dementia, and, eventually, death.

While there is no cure for HIV, effective antiretroviral treatments can help control the virus, enabling many individuals to live long, healthy lives.

Gonorrhoea

This is an infection caused by Neisseria gonorrhoeae (commonly referred to as gonococcus bacteriae). This infection is transmitted by involving in sexual activities and is one of the oldest recorded STDs. More than one million women are estimated to be infected with gonorrhoea globally. Many of these women are also co-infected with chlamydia, another bacterial sexually transmitted disease.

Contrary to some myths, this disease cannot be contracted through door handles or sharing toilet seats. The bacteria require specific circumstances for survival and can't live out of the body for long. It thrives on any moist surface within the body, such as the cervix, vagina, rectum, throat, and urethra.

Symptoms of gonorrhoea

Most women with gonorrhoea do not experience any symptoms, particularly in the early stage. However, when symptoms occur, they may include:

• Vaginal itching or burning
• Redness and swelling of the genitals
• Burning during urination
• Frequent urination
• Yellowish vaginal discharge

If untreated, this disease can cause a serious infection affecting the pelvis, including PID (pelvic inflammatory disease), which may lead to infertility or ectopic pregnancy. In severe cases, the infection can spread to joints, causing gonococcal arthritis, or develop into an abscess requiring surgical intervention.

Diagnosing and testing for gonorrhoea

During diagnosis, the infected areas (cervix, rectum, throat) are swabbed to detect bacteria through cultures or DNA-based tests, such as polymerase chain reaction (PCR). Modern genetic tests are more expensive but yield faster and more accurate results compared to older culture methods.

Gonorrhoea treatment

While gonorrhoea was once treatable with a single penicillin injection, antibiotic resistance has complicated treatment.

Currently, first-line treatments include:

• Oral cefixime for uncomplicated infections
• A single injection of ceftriaxone

Since gonorrhoea and chlamydia often co-occur, treatments typically address both infections. This includes azithromycin or doxycycline. Sexual partners must also be treated to prevent reinfection. Women with PID or systemic infections require more aggressive therapies, often involving intravenous antibiotics. Condom use is an effective preventive measure, as the bacteria cannot survive outside the body for long.

Chlamydia

This infection is caused by Chlamydia trachomatis, a bacterium that infects the rectum, throat, urethra, and cervix. It is one of the most common STDs, with approximately 2.9 million infections occurring annually in the United States alone. Both men and women may carry the infection without showing symptoms, contributing to its widespread transmission.

Chlamydia symptoms

Most women with this infection are asymptomatic. However, symptoms can include:

• Frequent or painful urination
• Vaginal discharge
• Abdominal pain

Untreated chlamydia can damage the fallopian tube, leading to severe pelvic infections like PID, ectopic pregnancy, or infertility. Pregnant women can pass the infection to their newborns, resulting in pneumonia or eye infection.

Chlamydia diagnosis and treatment

• Diagnosis is performed using non-invasive urine tests or swabs. Advanced DNA-based methods have replaced traditional culture techniques due to their accuracy and efficiency.
• Treatment involves the use of antibiotics, with doxycycline and azithromycin being the most commonly prescribed medications prescribed. In contrast to gonorrhoea, chlamydia has not developed significant resistance to antibiotics.

Condom use effectively reduces the risk of chlamydia transmission.

Syphilis

This disease is a century-old sexually transmitted disease caused by the spirochete bacterium Treponema pallidum. It infects the mucous membranes of the genitalia and mouth, producing a characteristic painless chancre ulcer.

Stages of syphilis

Syphilis progresses through three stages:

Primary stage: A chancre develops within 10-90 days of exposure.

Secondary stage: White patch in the vaginal area, the nose and mouth, rash, fever, loss of hair, and swollen lymph nodes occur if untreated.

Tertiary stage: Severe complications affecting the brain (sensation issues, mental confusion, etc.), ears (may lead to deafness), heart, and other organs (gummas) may develop years later. Here, the disease cannot be passed to another person.

Syphilis can also enter a latent phase, where symptoms disappear, but the infection persists.

Syphilis treatment and diagnosis

Blood tests and examination of the chancre under a microscope are used to diagnose syphilis. RPR (rapid plasminogen reagent) test and VDRL (venereal disease research lab) are the standard blood tests for syphilis, which detect how the body responds to the infection and not the actual organism that causes the infection.

Early-stage syphilis is treatable with penicillin, especially in pregnant women, as other medications cannot pass the placenta effectively to treat the foetus that is infected. However, if the disease is not treated, the case can progress, leading to serious complications.

Herpes (genital herpes)

Herpes, often referred to simply as Genital herpes, is an infection caused by the HSV (herpes simplex virus). It spreads through close contact with the mucous membranes of the genital skin, vagina, or mouth. This virus enters the body through tiny, often imperceptible tears in these areas. Once it gets inside, it travels to the roots of the nerve close to the spinal cord, where it remains dormant.

During an outbreak, the virus moves along the nerve fibres back to the original infection site, causing symptoms such as blistering and redness. After the initial episode, the outbreak may occur sporadically, ranging from weeks to years apart.

Two strains of the herpes virus are linked to genital infections: HSV-1 and HSV-2. HSV-1 is more commonly associated with oral blisters, while HSV-2 tends to cause sores in the genital or anal regions. The frequency and severity of herpes outbreaks are influenced by the immune system. Individuals with weakened immunity due to stress, other infections, or medication may experience more frequent and severe episodes.

This virus is transmitted solely through direct contact with an infected person. A significant number of adults who are sexually active are already infected with this virus, partly because many infected individuals are unaware they have it, as their symptoms can be minimal or absent. Women may experience uncharacteristic outbreaks, with slight discomfort or a mild itch being the only sign. Over time, outbreaks become less noticeable, and the virus may even shed from the cervix without causing symptoms, allowing for unintentional transmission.

Genital herpes symptoms

After exposure, the virus typically incubates for 3 to 7 days before symptoms appear. During this period, the virus is inactive and cannot be passed to another person. An outbreak often starts within fourteen days of infection, starting with a tingling feeling or itch, followed by blister formation and skin redness. The blisters, which may develop into painful ulcers, usually persist 1- 2 weeks.

Herpes is highly communicable from the onset of itching until the ulcers fully heal, typically within 14 to 28 days. However, it is important to note that the virus can be transmitted even when there are no visible symptoms.

Diagnosing genital Herpes

It can be suspected that one has contracted this disease when numerous aching blisters appear in any sexually uncovered area. During the first outbreak of symptoms, fluid from the blisters may be tested in a laboratory to confirm the presence of herpes simplex virus. However, this method is only about 50% reliable, as a negative result does not necessarily rule out infection. A positive result is highly reliable, particularly from a newly formed blister.

Blood tests that detect the herpes simplex virus (HSV-1 or HSV-2 antibodies) may also be used, particularly to identify infections without clear symptoms. However, these tests are not routinely recommended for screening low-risk populations due to the potential for false-positive results and ambiguous interpretations. Advanced techniques such as a rapid fluorescent antibody test and PCR (polymerase chain reaction) testing are available in some laboratories for more precise detection.

Genital herpes treatment

While there is no cure for this disease, antiviral medications can manage outbreaks by reducing their severity and duration. Oral treatments like Valtrex (valacyclovir), Zovirax (acyclovir), and Famvir (famciclovir) are commonly prescribed. Topical treatments, although available, are less effective and not widely used. In severe cases, intravenous antiviral therapy may be required.

The first outbreak is usually the most severe, and antiviral medication is highly effective in easing symptoms and promoting healing. However, it does not reduce the likelihood of future episodes. For recurring symptoms, antiviral drugs are most effective if started at the first sign, such as the formation of blisters or a tingling feeling.

For individuals who experience more than six outbreaks per year, suppressive therapy may be recommended. Daily doses of antiviral medications like acyclovir can help reduce the frequency of recurrences.

How to prevent the spread of herpes

• Avoid sharing clothing or personal items that have come into contact with sores.
• Pregnant women with herpes should inform their doctor, as active outbreaks during labour can pose risks to the baby. A vaginal delivery is possible if there are no symptoms or outbreaks during labour.
• Consistently use condoms during sexual activity, though they do not completely eliminate the risk of transmission.
• Avoid touching the eyes or mouth after contact with blisters or ulcers.
• Practise thorough handwashing during outbreaks.
• Abstain from sexual contact, including kissing, during outbreaks.

Genital warts and HPVs (human papillomaviruses)

Human papillomaviruses (HPVs) are a group of over 40 viral types that infect the genital tract of females and males, causing condylomata acuminate (commonly known as genital warts). These warts are usually spread through sexual contact. Different types of Human papillomaviruses are responsible for common warts on other parts of the body.

HPV is the most common sexually transmitted disease globally. Most people of reproductive age are thought to have been exposed to it at a point in their lives. HPV infections are often asymptomatic, meaning many individuals are unaware they carry the virus. While most cases do not lead to cancer or visible wart, some HPV types are linked to penile, anal, and cervical cancers.

The immune system's ability to clear HPV infections remains uncertain, and the virus may remain in the body indefinitely. Asymptomatic individuals can still transmit HPV to others through sexual contact.

Diagnosing genital warts and human papillomavirus

Diagnosing human papillomaviruses is often based on the characteristic appearance of genital warts. These warts are typically raised, small, and flesh-coloured, however, they can sometimes grow extensively and resemble a cauliflower. They can appear anywhere in a sexual area that is exposed. While warts are often painless, some individuals may experience tenderness, burning, or itching.

It may sometimes be detected through abnormalities seen on a Pap smear. If a smear indicates a potential HPV infection, further testing can confirm the virus type. In some cases, a wart or cervical lesion biopsy may be necessary for a definitive diagnosis.

Genital warts and human papillomavirus treatment

No treatment or cure completely eradicates human papillomaviruses. Treatment focuses on removing visible warts, though this does not prevent recurrence or the spread of the virus.

Patients may use medications such as:

• Sinecatechin Ointment: A green tea extract applied three times daily for up to 16 weeks.
• Podofilox: A 0.5% solution or gel applied twice daily for three days, followed by four days of no treatment.
• Imiquimod: A 5% cream applied three times a week at bedtime and washed off after 6 to 10 hours. This substance stimulates the body to produce cytokines (a chemical that strengthens and directs immune responses).

Physician-administered treatments include:

• Surgical removal of warts, laser surgery, or cryotherapy (using liquid nitrogen to freeze the wart).
• Podophyllin resin solutions were applied and later washed off.
• BCA (bichloroacetic acid) or TCA (Trichloroacetic acid) is applied weekly.

For women with precancerous cervical changes caused by HPV, procedures like conisation, cryotherapy, or laser therapy may be performed to remove or destroy affected tissue.

Vaccination for human papillomavirus

The vaccine, Gardasil, protects against four common HPV types associated with cervical, and anogenital cancer and genital warts. It is approved for females and males aged 9 to 26. Regular Pap smears remain crucial for women, even if vaccinated, to monitor for cervical abnormalities.

Chancroid

This is a bacterial infection caused by the Haemophilus ducreyi, primarily transmitted through sexual contact. It begins as a tender bump in areas of the genital skin, commonly the vulva in women and the penis in men. This bump typically appears within three to ten days following exposure. Over time, the cells within the bump deteriorate, leading to the formation of an open, painful sore (ulcer). Swollen and tender lymph nodes in the private part often accompany these ulcers in around one-third of cases. While chancroid is prevalent in developing nations, it is a relatively uncommon cause of genital ulcers in the United Kingdom.

Diagnosing chancroid

A diagnosis is made if one or more painful genital ulcers are present and tests for herpes and syphilis are negative. The term "chancroid" means to resemble a chancre, which is the genital sore caused by syphilis. Unlike the hard and painless chancre of syphilis, chancroid ulcers are soft and painful. Diagnosis can be verified by culturing material from the ulcer to detect Haemophilus ducreyi. Treatment may commence based on clinical findings alone, even without culture results.

Treating chancroid

This disease is generally treated effectively with an injection of ceftriaxone or one oral dose of azithromycin. Treatment typically resolves the ulcers within a week. If no progress is observed, further evaluation for other potential causes of genital ulcers is necessary. Alternatives include erythromycin or ciprofloxacin. People living with HIV are at a higher risk of treatment failure and require close monitoring to ensure successful resolution.

What to do if exposed to chancroid

Anyone who has had sexual contact with an infected individual should seek medical advice. Even without visible symptoms, treatment is recommended, particularly if the exposure occurred within ten days of the partner's symptoms appearing.

Ectoparasitic infections: scabies and pubic lice

These infections are caused by small parasitic organisms, such as mites and lice, which spread by making contact with an individual, especially during sexual activity. These parasites affect the hair and skin, often leading to intense itch.

Pediculosis pubis (Pubic lice)

Pubic lice, commonly referred to as "crabs," are caused by the Phthirus pubis (crab louse), which inhabits body hair, especially the pubic hair. The lice are visible to the naked eye and often cause itching in the area that is affected.

Treatment involves using a 1% permethrin cream rinse, applied to the affected region and rinsed off after ten minutes. Another treatment includes piperonyl butoxide combined with pyrethrins. It is essential to launder bedding and clothing in hot water to prevent reinfection. All sexual partners within the previous month should undergo evaluation and treatment.

Scabies

This disease results from an infestation by the mite Sarcoptes scabiei, which burrows into the skin, causing itching and small bumps. Symptoms usually appear several weeks after exposure and tend to worsen at night. The condition can affect various parts of the body, including the trunk, buttocks, hands, and arms.

The recommended treatment is a 5% permethrin cream, applied from the neck down, and after 8 to 14 hours, it should be washed out. Treatment is often repeated after 7 days. Oral ivermectin is another option, though it carries a higher risk of side effects. In some cases, a 1% lindane lotion may be used, but caution is advised due to the potential for toxic reactions, particularly in pregnant women, young children, and individuals with irritated or damaged skin. Persistent itching may continue for up to two months after successful treatment.

Similar to pubic lice, all bedding and clothing should be washed in hot water. Household and close personal contacts from the previous month should also be examined and treated if necessary.

Preventing sexually transmitted infections (STIs)

The best way to prevent STIs is through awareness and precautionary measures. While condoms can reduce the risk of transmission for some infections, they do not provide complete protection. Monogamous relationships where neither partner has an STI offer the safest context for sexual activity.

Specialist care for STIs

Women with STIs can seek treatment from various healthcare professionals, including:

• Family doctors
• General practitioners (GPs)
• Paediatricians (for adolescent patients)

For conditions such as HIV or hepatitis, specialist input may be required from:

• Gastroenterologists
• Immunologists
• Obstetricians and gynaecologists also commonly treat STIs in women.
• Hepatologists

Key facts about STIs in women

Many STIs in women present without symptoms, making regular screening important.

• Bacterial STIs, such as gonorrhoea, syphilis, and chlamydia, can be cured with antibiotics.
• Complications of untreated STIs may include infertility and PID (pelvic inflammatory disease).
• Viral STIs, including chronic hepatitis B and HIV, have no cure but can be managed with medication.
• Common STIs include Zika virus, genital herpes, HPV, gonorrhoea, and the chlamydia.
• Condoms offer partial protection but are not 100% effective against all STIs.

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