When I worked in a clinic in Baltimore in the late 1990s, I saw plenty of patients with gonorrhea. The men knew they had a sexually transmitted infection: The classic yellow drip from the penis couldn’t be much else. But the women, more often than not, had no symptoms. They were flabbergasted when I’d tell them that a routine screening test had been positive for gonorrhea. The good news was that the treatment—an antibiotic shot or pills—was easy and effective.
But the days of a wham bam thank you ma’am, one-shot deal for gonorrhea may be numbered. According to a recent article in Antimicrobial Agents and Chemotherapy, gonorrhea, already No. 2 on the list of most reported sexually transmitted infections in the United States, could be headed for superbug status. That’s because a worrisome new type of gonorrhea—the H041 strain—isolated from a female sex worker's throat in Japan in January 2009 has been found to be highly resistant to the antibiotics known as the third-generation cephalosporins, currently the only reliable treatment for gonorrhea.
You may be thinking that you’ve heard these dire warnings before, and you’re right. Like other infectious bugs, the gonococcus—the microorganism that causes gonorrhea—is constantly finessing its ability to thwart one antibiotic after the other. But what’s different this time is that the cephalosporins are truly the end of the antibiotic line. If the new cephalosporin-resistant H041 strain catapults around the globe, the consequences will be ugly, particularly for young women. Gonorrhea has been hitting women hard for years, in many ways: not only have women been blamed for spreading the disease and endured barbaric treatments, but they’re incredibly susceptible to catching gonorrhea from infected men and are more likely to develop complications. If gonorrhea truly becomes untreatable, it’s women who will have the most to lose.
The gonococcus has been resisting treatments and vying for superbug status for thousands of years. In the preantibiotic era, treatments for gonorrhea were often worse than its symptoms. Some 18th and 19th century doctors injected caustic solutions of silver nitrate or potassium permanganate into the urethra or vagina, while others inserted long, thin metal rods in the penile urethra. In an early 20th century heat treatment, hot water, up to 120 degrees Fahrenheit, would be flushed through the vagina for 15 minutes twice daily.
Then came penicillin in the mid 1940s, and with it, a true cure for gonorrhea. Or so it seemed. Over the years, however, as the gonococcus has buffed up its defenses to antibiotics, doctors have had to prescribe higher and higher doses to combat it. Dr. Edward Hook, a professor of medicine at the University of Alabama at Birmingham told me that the dose of penicillin for treating gonorrhea increased more than 100-fold from the mid-1940s to 1989, when it was no longer recommended for treatment of gonorrhea, because even the highest doses had stopped working. One by one, the bug knocked off once highly-effective antibiotics: penicillin, tetracycline, and in more recent years the fluoroquinolones (like Cipro).
Until now, there was always another antibiotic to use. But the cephalosporins are the last class standing, and the emergence of the H041 strain that is outsmarting cephalosporins in Japan means that their time may also be limited. Resistance to this class of antibiotics will likely follow the pattern of resistance to ciprofloxacin, which the CDC stopped recommending for gonorrhea back in 2007. The drug’s first treatment failures were in Asia, but the West Coast and then the East Coast soon followed. Back then, though, we still had the cephalosporins as a drug of last resort. This time, there are no new drugs on the horizon.
Unlike the HIV epidemic that’s been disproportionately hard on young men, an era of untreatable gonorrhea stands to hit young women the hardest. Women have always been the hardest hit victims of the disease, both socially and medically. During World War I, U.S. military campaigns urged men to avoid “easy” women, the purported source of venereal infections. Many a military public health poster featured a lascivious woman luring men into her den of sin; one such poster reads “A German bullet is cleaner than a whore”; another, entitled “Booby Trap,” depicts a smiling brunette with a plunging décolletage, clearly up to no good. During both World Wars, prostitutes were arrested and often quarantined. A patient of mine who served in the Army in the early 1940s recalls “mountain girls” who “took advantage” of soldiers on their paydays by taking their money-and leaving them with the clap.
Perhaps women wouldn’t have gotten such a bad rap if the mechanics of the disease had been better understood. If you’re female, you’re almost guaranteed to catch the infection during vaginal sex with an infected man: A single unprotected act of intercourse will cause infection 70-80 percent of the time. Compare that with HIV, where a heterosexual couple can have intercourse regularly over months without one infected partner infecting the other. And up to 50 percent of infected women, like many of my patients in Baltimore in the 1990s, have no idea that they’re infected. On top of this, while gonorrhea usually clears up without serious problems in men, women are more likely to suffer long-term complications, including pelvic inflammatory disease, which can lead to tubal scarring, infertility, chronic pelvic pain, and ectopic pregnancy. If gonorrhea emerges as a drug-resistant superbug anytime soon, those complications will again be common.
Making matters worse for young women, most of the gonorrhea cases examined by the CDC are not among young women but men (including many men who have sex with men). That’s because the CDC’s Gonorrhea Isolate Surveillance Project tracks gonorrhea in publicly funded STI clinics across the country—but only gonorrhea in men with urethral symptoms. Moreover, it does not gather information on the less-studied and harder to treat strains of pharyngeal gonorrhea—gonorrhea of the throat—such as the new strain found in Japan. As Dr. Noni MacDonald, a professor of pediatrics at Dalhousie University in Nova Scotia and the author of a recent editorial in the Canadian Medical Association Journal highlighting the potential dangers of widespread drug-resistant gonorrhea, told me: “We don’t know what’s happening to 19- and 20-year-olds who go to private doctors. We need to know where the illness is.”
For now, this much is clear: Gonorrhea has superbug potential, and women, especially young women, are poised to suffer the most. Although efforts to develop a new antibiotic should form a critical first line of defense, it won’t be the end of the gonorrhea story: resistance seems inevitable, eventually, for every antibiotic. It is just as important, therefore, to find more equitable ways to track the disease—ways to follow patterns of infection and antibiotic resistance in women, not just in men—and to promote early detection and prompt treatment.
Earlier this year in Canada, after the Alberta government highlighted the rising number of syphilis cases with a parody of the Plenty of Fish dating website—called plentyofsyph.com—STI testing rates skyrocketed. Perhaps an American counterpart could help spread the word about gonorrhea. G-date, anyone?