CHLAMYDIA

Chlamydia is the most commonly reported sexually transmitted disease in the United States. Thirty to 40%—nearly half—of the 3 million new cases each year occur in teens between the ages of 15 and 19.¹

While health officials think its prevalence is declining in the general population, it continues to wreak havoc among teens. Teenage girls are most affected; about one in ten has the disease, compared with boys, in whom the numbers are closer to one in 20.² Just picture your daughter’s soccer team. If all those girls are sexually active, at least one girl on that team is likely to have chlamydia. There are two primary reasons for the high numbers of chlamydia in teenage girls. First, about 85% of women and half of all men with the disease have no symptoms.³ Because teens rarely see a doctor unless they’re sick, it’s hard to know if they’re infected. And, of course, if they don’t know they’re sick, they can’t be treated, and so they keep spreading the disease through sexual activity.

Second, chlamydia is hard to culture. When I perform a pelvic exam on a teenage girl, I take samples of cells from her cervix and vagina. I would pick up chlamydia only if the bacteria stayed in those areas. But sometimes, as the germ travels upward through the fallopian tubes and into organs beyond the uterus, it leaves the cervix. Thus, my cultures turn up negative for chlamydia, even though the girl is infected.

The only way to culture an infection in the uterus, fallopian tube, or any structure outside the uterus is through a surgical procedure called a laparoscopy, in which a gynecologist inserts a special instrument through an incision in the abdomen to examine the pelvic organs and take a tissue sample. This is a serious, invasive procedure, which we do not undertake lightly.

At first, the bacteria enters a girl’s vagina and climbs toward the uterus, fallopian tubes, and ovaries. The primary symptoms are tenderness and a slight vaginal discharge. I always hope a girl has these symptoms, because then I might get to treat her early. But it’s just as likely she won’t know anything is wrong.

If chlamydia stays in a girl’s cervix and doesn’t spread, the disease lasts about 15 months and may clear up on its own. Other times, however, chlamydia spreads. Left untreated, chlamydia will cause PID in 20 to 40% of cases.⁴ This results in severe abdominal pain, tenderness, and fever. If the chlamydia infection moves beyond a woman’s reproductive organs into her abdominal cavity, it can cause scarring around her liver and diaphragm in a condition called the Fitz-Hugh and Curtis syndrome. It occurs in about 20% of young women with PID.⁵ We can use antibiotics to heal the bacterial infection, but nothing can remove the scarring, which may result in chronic pain.

Once chlamydial infection develops into PID, infertility becomes a real threat. A startling one in four women with PID experiences problems such as ectopic pregnancy (pregnancy outside the uterus) or infertility.⁶

Infertility occurs in a variety of ways. The infection may scar a fallopian tube, and the scar tissue may block the tube. Since the fertilized egg travels along the fallopian tube to the uterus before implanting into the uterine wall to begin growing, this blockage would, effectively, stop any pregnancies. But in some instances, the fertilized egg can implant in the fallopian tube itself, causing an extremely dangerous condition called ectopic pregnancy. As the embryo grows, the tube eventually bursts and the young woman may die. Even if an infected woman is lucky enough to get pregnant, her baby is at risk of being born with eye infections and pneumonia.

Infertility is one of the most emotionally heartbreaking problems women can experience. And PID is one of the top reasons so many women experience infertility. Sadly, much of PID results from STDs acquired during the teen years.

Sandy’s Story

I watched Sandy struggle with PID as a 17-year-old. She came to my office because she was having fits of abdominal pain that just wouldn’t go away. She went to an urgent care center and the doctor told her she was experiencing severe constipation. He told her to go home and try some laxatives. She did. She came into my office three days later doubled over. When I examined her abdomen, she was in so much pain that she didn’t even want me to touch her anywhere. When I told her that I needed to do a pelvic exam, I really believe she was so angry at me that she would have run out of the room if she could have.

When I performed the pelvic exam, she nearly jumped off the table when I moved her cervix. Her entire uterus was tender and inflamed, and I could tell just from examining her that the infection had moved into her fallopian tubes and was beyond her uterus. I took some cultures, which confirmed my suspicion of chlamydia, and admitted Sandy to the hospital so we could give her intravenous antibiotics. She responded well to the antibiotics and she behaved six months later as though she’d forgotten all about her experience. Sure enough, eventually she came back into my office with the same diagnosis and needed the same antibiotics. Repeat chlamydial infections are all too common in teens.

I was lucky enough to attend Sandy’s wedding a couple of years later. She looked beautiful and excited, and married a terrific guy. As I watched her walk down the aisle, I felt a deep sadness. I knew what probably no one else at the wedding except Sandy knew. She was gorgeous and young and had so many years to look forward to. Would children be in her future? They could be, but the sad truth is, she markedly decreased her chances of having children because she had sex when she was too young. Chlamydia and PID change futures for way too many young women and men.

You see, chlamydia is gender-neutral, infecting men with nearly as much vigor. Although chlamydia does cause more damage in women, it harms boys as well, and 40% of males who are infected have no symptoms.⁷ In males, the bacteria can result in infections of the internal genital organs, the epididymis, prostate, and urethra, making urination difficult. Fortunately, the disease doesn’t cause infertility in men, and a course of antibiotics can wipe out the infection with no lasting effects. But an untreated infection may cause narrowing of the urethra or Reiter’s syndrome, which causes conjunctivitis (an eye infection), infection of the urethra, arthritis, and unusual sores in the mouth. Chlamydia can also cause blood infections and arthritis in both men and women.

Frequently, I treat a patient for chlamydia only to see her return nine months later with another chlamydial infection. Why? Because often teens fail to change their sexual patterns even after they’ve had a wake-up call like an STD. This is a particular problem with an easily cured STD like chlamydia. Since a dose of antibiotics often clears up the infection, many young teens think it’s no big deal and go right back to their risky sexual patterns.

GONORRHEA: BACK WITH A VENGEANCE

Gonorrhea used to be the good-news story on the STD front. While new diseases, including HIV, reared up in the 1980s and 1990s, rates of gonorrhea plummeted, thanks to intense public education, detection, and treatment campaigns on the part of public health officials. In the late 1990s, however, the disease bounced back. Now an estimated 650,000 cases are reported each year, and the actual number of gonorrhea infections is believed to be nearly twice that.⁸

But the statistic that most concerns me is this one: Gonorrhea rates are highest among young women between the ages of 15 and 19.⁹

One reason for the rising rates in adolescents may be the rising incidence of risky sexual behavior among teenagers. The more partners they have, the higher the risk of gonorrhea. And the wilder the sex (group sex, multiple partners in one night), the higher the rate of STDs. I’ll discuss this in more detail in Chapter 9.

Gonorrhea is also a major cause of PID, infertility, ectopic pregnancy, and chronic pelvic pain in women. In women and men, gonorrhea can get into the bloodstream and cause septicemia and joint problems. Can you imagine a college senior with severe osteoarthritis? My colleague recently treated one.

Although patients are rarely hospitalized for arthritis, this young man was. Chip was 20 and had been sexually active since he was 15. He had tried heterosexual sex, then tried sex with men and liked it better. So he found one partner, then another, then more. Sometimes he used condoms, he said, sometimes he didn’t. He had been treated for gonorrhea once, but it returned after he had sex with an infected man. He admitted that he didn’t consider his first bout of gonorrhea “a big deal,” since it was easily cured with antibiotics. But then he began having knee pain and fevers that came and went. When his knee became so swollen and painful he couldn’t walk, he sought medical help. He didn’t recall ever hurting his knee.

He was fortunate enough to see an astute physician who thought to take a sexual history. When the young man revealed his homosexuality, the doctor did a blood test and diagnosed the cause of his arthritis—the gonorrhea circulating throughout his blood. If he’d missed the infection and the disease remained untreated, at a minimum the bacteria would have continued to eat away at his knee joint, causing permanent damage. Or, the bacteria could have multiplied in his bloodstream, causing serious heart infection and perhaps death. In fact, in the era before antibiotics, gonorrhea caused 10% of all cases of endocarditis, an infection in the lining of the heart.

The young man was lucky. The intravenous antibiotics quelled the infection. Next time, however, he might not be so fortunate.

In the past few years, health officials have identified an alarming trend: increasing numbers of gonorrhea infections that are resistant to fluoroquinolones, the class of antibiotics typically used to treat them. Gonorrhea had become resistant to simple penicillin years ago. When bacteria like gonorrhea learn to outsmart antibiotics, there is only one thing to do: use stronger antibiotics. But it’s only a matter of time before the bacteria outsmart those drugs.

So far, we’ve continued to win the race against antibiotic-resistant bacteria by coming up with more and more powerful medicines. But tucked in the recesses of many physicians’ minds is the fear that there will come a time when medications can no longer stay one step ahead of the bacteria. Our medical armamentarium will be empty. The bacteria will win.

SYPHILIS INCOGNITO

The famous physician William Osler, M.D., once said, “He who knows syphilis, knows medicine.” Syphilis is called “the great mimicker” because it can mimic the symptoms of virtually any disease, making it very difficult to diagnose. It is one of the oldest known STDs—its victims included Pope Alexander VI, Ivan the Terrible, and King Henry VIII. Unfortunately, these days its victims could include your niece or nephew.

Syphilis causes problems in men and women beyond the reproductive system. Left untreated, it advances through three stages. The first is called primary syphilis, in which a sore, or “chancre,” appears on the genitalia. These ulcers are often hidden deep within the reproductive tract in women, who are usually unaware of them. The sore is not painful (like herpes sores can be) and usually clears up on its own even if not treated. But they increase the likelihood of sexual transmission of the HIV virus two- to fivefold.

If the patient doesn’t recognize the sore and fails to get treatment, syphilis progresses to the secondary stage. The victim develops a rash of reddish-brown spots on the palms of his hands and the soles of his feet. The rash can also occur on other parts of the body. But it’s identical to many other rashes, and so is often misdiagnosed. Again, even without treatment, the rash goes away on its own, but the syphilis bacteria remains in the body.

At the onset of the third stage, the bacteria attacks the heart, the nervous system, eyes, blood vessels, liver, bones, and joints. A person with this late stage of syphilis experiences paralysis, numbness, difficulty coordinating his muscles, gradual blindness, and dementia. Death is a very real possibility.

That’s why it’s so important that physicians diagnose syphilis as early as possible in the course of the disease. With antibiotic treatment, syphilis can be stopped at either of the first two stages, thus preventing the final destruction of tissues and organs in the third stage.

Infected mothers can also pass the disease onto their babies. Infants born with syphilis commonly have multiple, severe problems of the brain and nervous system. They may have developmental delays, seizures, and brain damage, and they often die. Nearly 25% of pregnant women infected with the disease will miscarry.¹⁰

Years ago, as a pediatric resident working in a large inner-city hospital, I took care of a premature baby who began having seizures shortly after birth. She was a big baby for 35 weeks—about 6 pounds. And she was beautiful, with clear, caramel-colored skin. We successfully treated her seizures with an anticonvulsant. Although her mother denied having any STDs, we knew better than to trust her memory, so we tested the baby for syphilis. Her test came back positive.

I felt sick. I knew when I saw the result that we were in for a hard row. Sure enough, her seizures returned and got worse. We gave her more and more medication and finally she developed intractable seizures that medication couldn’t affect. As the baby seized and writhed I felt horribly helpless. We’d killed the bacteria in her blood, but its effects on her brain were overwhelming. As her heart rate slowed and we knew she was dying, we took her off life support and I held her in my arms as the life in her flickered out. I wanted to take her to her mother, but the woman said she couldn’t hold the baby—she was too distraught herself.

Syphilis had changed this family forever.

It is a horrible disease, but there is some good news on the syphilis front. Rates of syphilis in this country are at their lowest levels ever, and federal health officials have launched a plan to eradicate the disease entirely in the coming years. This disease is also less prevalent among teenagers; the highest rates are among women ages 20 to 29 and men ages 35 to 39.¹¹ That doesn’t mean that sexually active teens never get this infection. They do, and it remains a serious danger. Gonorrhea rates had fallen a few years ago. Now they’re back, stronger than ever. Syphilis may easily do the same.

TRICHOMONIASIS: HIV’S LITTLE HELPER

Trichomoniasis, a common STD in men and women, is caused by a parasite. It is not a bacterium, but we clump it with bacterial STDs because it responds to antibiotic treatment.

An estimated 5 million new infections occur each year, about one-fourth in teens (a very conservative estimate).¹² The organism that causes trichomoniasis has three tails and swims in the vagina, very much like sperm. Men usually have no symptoms, but some have burning with urination and ejaculation and a mild penile discharge. Some young women experience vaginal burning and itching and have a yellow-green frothy discharge, but 20 to 50% of women have no symptoms.¹³ This makes the actual prevalence of trichomoniasis infection hard to establish. Additionally, even those women who do have symptoms often don’t seek medical attention; they think the discharge and itching are due to menstrual problems or a yeast infection.

Left untreated, however, girls with trichomoniasis continue to infect their sexual partners, and have a higher risk of premature rupture of membranes during pregnancy and preterm delivery. One of the most serious problems with trichomoniasis is that it may increase the risk of HIV infection.¹⁴ We don’t really know why, since it doesn’t generate the open sores of syphilis or herpes. Perhaps an immune system already stressed from fighting off the trichomoniasis can’t effectively resist HIV.

Physicians treat trichomoniasis with oral medications such as Flagyl. However, the parasite has become increasingly resistant to treatment, and repeat courses of medication or higher doses are needed—sometimes delivered intravenously. As with any antibiotic-resistant bacteria, physicians fear that the trichomoniasis parasite may ultimately outsmart all our antibiotics.

BACTERIAL VAGINOSIS

Bacterial vaginosis is a very common infection in teen girls and women, often existing alongside sexually transmitted diseases. While it’s not officially a sexually transmitted disease, it is, indirectly, caused by sexual activity. That’s because sexual activity alters the balance of certain bacteria in the vagina, tipping the balance of good bacteria versus bad bacteria that normally reside there. This imbalance lets a harmful bacteria, called Gardnerella vaginalis, take over. The infection causes a grayish vaginal discharge with a fishy odor, and may occur even if a teen hasn’t been sexually active.

Like trichomoniasis, bacterial vaginosis leads to far greater problems, increasing the risk of PID and HIV infection. In pregnant women, the disease leads to premature births and low-birth-weight babies.

MY PATIENTS ARE YOUR CHILDREN

I remember a young teenager who died in the emergency room when I was a second-year pediatric resident. I’d failed to see that she was experiencing a fatal drug overdose, and thought she had an infection. She just didn’t look like my perception of what a drug addict looked like. Another physician reprimanded me after she died. “Didn’t you do a drug screen?” he asked in amazement.

“I just didn’t think about it,” I said.

“You can’t afford not to think about it,” he said. “These kids’ lives depend on you.”

I will never forget his words. Today they apply to this new epidemic, which we cannot ignore or refuse to think about. Failing to recognize this epidemic for what it is could kill our kids just as surely as that drug overdose took the life of that young woman.

Now that you’ve met some of my patients and seen a slice of the world I see every day, look around. My patients are just like your kids, your nieces and nephews, the teens at church with you on Sunday morning, at football practice, and at piano recitals. They are the potential victims of this epidemic.

In the following pages, you’ll learn about another epidemic—one that is gaining momentum and that proves to be as dangerous and perhaps even more painful than viruses and bacteria.