Sexually Transmitted Diseases (STDs)

Common STDs in women include chlamydia, gonorrhea, HPV, genital herpes, and the Zika virus.

Sexually transmitted diseases (STDs) are infections that can be transferred from one person to another through any type of sexual contact. STDs are sometimes referred to as sexually transmitted infections (STIs) since they involve the transmission of a disease-causing organism from one person to another during sexual activity. It is important to realize that sexual contact includes more than just sexual intercourse (vaginal and anal). Sexual contact includes:

• kissing,
• oral-genital contact, and
• the use of sexual "toys," such as vibrators.

STDs probably have been around for thousands of years, but the most dangerous of these conditions, the acquired immunodeficiency syndrome (AIDS or HIV disease), has only been recognized since 1984.

Many STDs are treatable, but effective cures are lacking for others, such as HIV, HPV, and hepatitis B, and hepatitis C. Even gonorrhea, once easily cured, has become resistant to many of the older traditional antibiotics. Many STDs can be present in, and spread by, people who do not have any symptoms of the condition and have not yet been diagnosed with an STD. Therefore, public awareness and education about these infections and the methods of preventing them are important.

There really is no such thing as "safe" sex. The only truly effective way to prevent STDs is abstinence. Sex in the context of a monogamous relationship wherein neither party is infected with an STD also is considered "safe." Most people think that kissing is a safe activity. But unfortunately, syphilis, herpes, and other infections can be contracted through this relatively simple and apparently harmless act. All other forms of sexual contact carry some risk. Condoms are commonly thought to protect against STDs. Condoms are useful in decreasing the spread of certain infections, such as chlamydia and gonorrhea; however, they do not fully protect against other infections such as genital herpes, genital warts, syphilis, and AIDS.

Prevention of the spread of STDs is dependent upon the counseling of at-risk individuals and the early diagnosis and treatment of infections.

Common STDs in women include chlamydia, genital herpes, human papillomavirus (HPV) infection, syphilis, gonorrhea, pubic lice, chancroid, and HIV/AIDS.

• In 2019 the Sexually Transmitted Disease Surveillance Report released US Centers for Disease Control and Prevention (CDC) showed that the three most common reportable STDs—syphilis, gonorrhea, and chlamydia—were on the rise.
• The numbers of syphilis and gonorrhea cases reported from 2017-2018 were higher than any point since 1991.
• The number of Chlamydia cases reported (almost 1.7 million cases) was the highest ever recorded.

A serious consequence of the increase in syphilis is a dramatic increase in the number of newborns affected by syphilis. Congenital syphilis is passed from a mother to the baby during pregnancy is a serious condition that can lead to miscarriage, stillbirth, newborn death, and severe medical and neurological problems.

What is gonorrhea?

Gonorrhea is a bacterial infection caused by the organism Neisseria gonorrheae (also known as gonococcus bacteriae) that is transmitted by sexual contact. Gonorrhea is one of the oldest known sexually transmitted diseases. It is estimated that over one million women are currently infected with gonorrhea. Among women who are infected, a significant percentage also will be infected with chlamydia, another type of bacteria that causes another STD. (Chlamydia infection is discussed later in this article.)

Contrary to popular belief, gonorrhea cannot be transmitted from toilet seats or door handles. The bacterium that causes gonorrhea requires very specific conditions for growth and reproduction. It cannot live outside the body for longer than a few minutes, nor can it live on the skin of the hands, arms, or legs. It survives only on moist surfaces within the body and is found most commonly in the vagina, and, more commonly, the cervix. (The cervix is the end of the uterus that protrudes into the vagina.) It can also live in the tube (urethra) through which urine drains from the bladder. Gonorrhea can also exist in the back of the throat (from oral-genital contact) and in the rectum.

Gonorrhea symptoms

The majority of infected women have no symptoms, especially in the early stages of the infection. When women do experience signs and symptoms of gonorrhea they include:

• burning during urination,
• frequent urination,
• a yellowish vaginal discharge,
• redness and swelling of the genitals, and
• vaginal itching or burning.

If untreated, gonorrhea can lead to a severe pelvic infection with inflammation of the Fallopian tubes and ovaries. Gonorrhea can also spread through the body to infect joints to cause gonococcal arthritis. Gonorrheal infection of the Fallopian tubes can lead to a serious, painful infection of the pelvis known as pelvic inflammatory disease or PID. PID occurs in a significant portion of women with gonorrheal infection of the uterine cervix. Symptoms of pelvic infection include fever, pelvic cramping, abdominal pain, or pain with intercourse. Pelvic infection can lead to difficulty in becoming pregnant or even sterility. Occasionally, if the infection is severe enough, a localized area of infection and pus (an abscess) form and major surgery may be necessary and even lifesaving. Gonorrhea infection in people with conditions causing serious abnormal immune function, such as AIDS, can also be more serious.

Testing and diagnosis of gonorrhea

Testing for gonorrhea is done by swabbing the infected site (rectum, throat, cervix) and identifying the bacteria in the laboratory either through culturing of the material from the swab (growing the bacteria) or identification of the genetic material from the bacteria. Sometimes the tests do not show bacteria because of sampling errors (the sampled area does not contain bacteria) or other technical difficulties, even when the woman has an infection. Newer tests to diagnose gonorrhea involve the use of DNA probes or amplification techniques (for example, polymerase chain reaction, or PCR) to identify the genetic material of the bacteria. These tests are more expensive than cultures but typically yield more rapid results.

Treatment of gonorrhea

In the past, the treatment of uncomplicated gonorrhea was fairly simple. A single injection of penicillin cured almost every infected person. Unfortunately, there are new strains of gonorrhea that have become resistant to various antibiotics, including penicillins, and are therefore more difficult to treat. Fortunately, gonorrhea can still be treated by other injectable or oral medications.

Uncomplicated gonococcal infections of the cervix, urethra, and rectum, are usually treated by a single injection of ceftriaxone or by oral cefixime (Suprax). For uncomplicated gonococcal infections of the pharynx, the recommended treatment is ceftriaxone in a single IM dose.

Alternative regimens for uncomplicated gonococcal infections of the cervix, urethra, and rectum include spectinomycin in nonpregnant women (not available in the United States) or single doses of other cephalosporins such as ceftizoxime or cefoxitin, administered with probenecid (Benemid), 1 g orally; or cefotaxime.

Treatment for gonorrhea should always include medication that will treat chlamydia [for example, azithromycin (Zithromax, Zmax) or doxycycline (Vibramycin, Oracea, Adoxa, Atridox, and others)] as well as gonorrhea because gonorrhea and chlamydia frequently exist together in the same person. The sexual partners of women who have had either gonorrhea or chlamydia must receive treatment for both infections since their partners may be infected as well. Treating the partners also prevents the reinfection of the woman. Women suffering from PID or gonococcal arthritis require more aggressive treatment that is effective against the bacteria that cause gonorrhea as well as against other organisms. These women often require intravenous administration of antibiotics.

It is important to note that doxycycline, one of the recommended drugs for the treatment of PID, is not recommended for use in pregnant women.

Gonorrhea is one of the easier STDs to prevent because the bacterium that causes the infection can survive only under certain conditions. The use of condoms protects against gonorrhea infection. Since the organism can live in the throat, condoms should be used during oral-genital contact as well.

What is chlamydia?

Chlamydia (Chlamydia trachomatis) is a bacterium that causes an infection that is very similar to gonorrhea in the way that it is spread and the symptoms it produces. It is common; estimates indicate 2.9 million infections occur annually in the U.S. Like gonorrhea, the chlamydia bacterium is found in the cervix and urethra and can live in the throat or rectum. Both infected men and infected women frequently lack symptoms of chlamydia infection. Thus, these individuals can unknowingly spread the infection to others. Another strain (type) of Chlamydia trachomatis, which can be distinguished in specialized laboratories, causes the STD known as lymphogranuloma venereum (LGV; see below).

Symptoms of chlamydia

The majority of women with chlamydia do not have symptoms. Cervicitis (infection of the uterine cervix) is the most common manifestation of the infection. While about half of women with chlamydial cervicitis have no symptoms, others may experience vaginal discharge or abdominal pain. Infection of the urethra is often associated with chlamydial infection of the cervix. Women with infection of the urethra (urethritis) have the typical symptoms of a urinary tract infection, including pain upon urination and the frequent and urgent need to urinate.

Chlamydia is very destructive to the Fallopian tubes. It can also cause severe pelvic infections. If untreated, some women with chlamydia will develop the pelvic inflammatory disease (PID; see above). Because it is common for infected women to have no symptoms, chlamydial infection is often untreated and results in extensive destruction of the Fallopian tubes, fertility problems, and tubal pregnancy.

Chlamydial infection, like gonorrhea, is associated with an increased incidence of premature births. In addition, the infant can acquire the infection during passage through the infected birth canal, leading to serious eye damage or pneumonia. For this reason, all newborns are treated with eye drops containing an antibiotic that kills chlamydia. Treatment of all newborns is routine because of the large number of infected women without symptoms and the dire consequences of chlamydial eye infection to the newborn.

Diagnosis of chlamydia

Chlamydia can be detected on material collected by swabbing the cervix during a traditional examination using a speculum, but noninvasive screening tests done on urine or on self-collected vaginal swabs are less expensive and sometimes more acceptable to patients. While culturing of the organism can confirm the diagnosis, this method is limited to research laboratories and forensic investigations. For routine diagnostic use, newer and inexpensive diagnostic tests that depend upon identification and amplification of the genetic material of the organism have replaced the older, time-consuming culture methods.

Treatment of chlamydia

Treatment of chlamydia involves antibiotics. A convenient single-dose therapy for chlamydia is oral azithromycin (Zithromax, Zmax). Alternative treatments are often used, however, because of the high cost of this medication. The most common alternative treatment is doxycycline (Vibramycin, Oracea, Adoxa, Atridox, and others). Unlike gonorrhea, there has been little, if any, resistance to chlamydia to current antibiotics. There are many other antibiotics that also have been effective against chlamydia. As with gonorrhea, a condom or other protective barrier prevents the spread of the infection.

What is syphilis?

Syphilis is an STD that has been around for centuries. It is caused by a bacterial organism called a spirochete. The scientific name for the organism is Treponema pallidum. The spirochete is a wormlike, spiral-shaped organism that wiggles vigorously when viewed under a microscope. It infects the person by burrowing into the moist, mucous-covered lining of the mouth or genitals. The spirochete produces a classic, painless ulcer known as a chancre.

Symptoms of syphilis

There are three stages of syphilis, along with an inactive (latent) stage. The formation of an ulcer (chancre) is the first stage. The chancre develops any time from 10 to 90 days after infection, with an average time of 21 days following infection until the first symptoms develop. Syphilis is highly contagious when the ulcer is present.

The infection can be transmitted from contact with the ulcer that teems with spirochetes. If the ulcer is outside of the vagina or on the male's scrotum, condoms may not prevent transmission of the infection by contact. Similarly, if the ulcer is in the mouth, merely kissing the infected individual can spread the infection. The ulcer can resolve without treatment after three to six weeks, but the disease can recur months later as secondary syphilis if the primary stage is not treated.

In most women, an early infection resolves on its own, even without treatment. However, some will proceed to the second stage of the infection called "secondary" syphilis, which develops weeks to months after the primary stage and lasts from four to six weeks. Secondary syphilis is a systemic stage of the disease, meaning that it can involve various organ systems of the body. In this stage, patients can initially experience many different symptoms, but most commonly they develop a skin rash, typically appearing on the palms of the hands or the bottoms of the feet, that does not itch. Sometimes the skin rash of secondary syphilis is very faint and hard to recognize; it may not even be noticed in all cases. This secondary stage can also include hair loss, sore throat, fever, headaches, and white patches in the nose, mouth, and vagina. There can be lesions on the genitals that look like genital warts but are caused by spirochetes rather than the wart virus. These wart-like lesions, as well as the skin rash, are highly contagious. The rash can occur on the palms of the hands, and the infection can be transmitted by casual contact.

After secondary syphilis, some patients will continue to carry the infection in their bodies without symptoms. This is the so-called latent stage of the infection. Then, with or without a latent stage, which can last as long as 20 or more years, the third (tertiary) stage of the disease can develop. At this stage, syphilis usually is no longer contagious. Tertiary syphilis is also a systemic stage of the disease and can cause a variety of problems throughout the body including:

1. abnormal bulging of the large vessel leaving the heart (the aorta), resulting in heart problems;
2. the development of large nodules (gummas) in various organs of the body;
3. infection of the brain, causing a stroke, mental confusion, meningitis (type of brain infection), problems with sensation, or weakness (neurosyphilis);
4. involvement of the eyes leading to sight deterioration; or
5. involvement of the ears resulting in deafness. The damage sustained by the body during the tertiary stage of syphilis is severe and can even be fatal.

Diagnosis of syphilis

Syphilis can be diagnosed by scraping the base of the ulcer and looking under a special type of microscope (darkfield microscope) for the spirochetes. However, because these spirochetes are rarely detected, the diagnosis is most often made and treatment is prescribed based upon the appearance of the chancre. Diagnosis of syphilis is complicated by the fact that the causative organism cannot be grown in the laboratory. Therefore, cultures of affected areas cannot be used for diagnosis.

Special blood tests can also be used to diagnose syphilis. The standard screening blood tests for syphilis are called the Venereal Disease Research Laboratory (VDRL) and Rapid Plasminogen Reagent (RPR) tests. These tests detect the body's response to the infection, but not to the actual Treponema organism that causes the infection. These tests are thus referred to as non-treponemal tests. Although the non-treponemal tests are very effective in detecting evidence of infection, they can also produce a positive result when no infection is present (so-called false-positive results for syphilis). Consequently, any positive non-treponemal test must be confirmed by a treponemal test specific for the organism causing syphilis, such as the microhemagglutination assay for T. pallidum (MHA-TP) and the fluorescent treponemal antibody absorbed test (FTA-ABS). These treponemal tests directly detect the body's response to Treponema pallidum.

Treatment of syphilis

Depending on the stage of disease and the clinical manifestations, the treatment options for syphilis vary. Long-acting penicillin injections have been very effective in treating both early and late-stage syphilis. The treatment of neurosyphilis requires the intravenous administration of penicillin. Alternative treatments include oral doxycycline or tetracycline.

Women who are infected during pregnancy can pass on the infection to the fetus through the placenta. Penicillin must be used in pregnant patients with syphilis since other antibiotics do not effectively cross the placenta to treat the infected fetus. Left untreated, syphilis can lead to blindness or even death of the infant.

What is genital herpes?

Genital herpes, also commonly called "herpes," is a viral infection by the herpes simplex virus (HSV) that is transmitted through intimate contact with the mucous-covered linings of the mouth or the vagina, or the genital skin. The virus enters the linings or skin through microscopic tears. Once inside, the virus travels to the nerve roots near the spinal cord and settles there permanently.

When an infected person has a herpes outbreak, the virus travels down the nerve fibers to the site of the original infection. When it reaches the skin, the typical redness and blisters occur. After the initial outbreak, subsequent outbreaks tend to be sporadic. They may occur weekly or even years apart.

Two types of herpes viruses are associated with genital lesions: herpes simplex virus-1 (HSV-1) and herpes simplex virus-2 (HSV-2). HSV-1 more often causes blisters of the mouth area while HSV-2 more often causes genital sores or lesions in the area around the anus. The outbreak of herpes is closely related to the functioning of the immune system. Women who have suppressed immune systems, because of stress, infection, or medications, have more frequent and longer-lasting outbreaks.

Genital herpes is spread only by direct person-to-person contact. It is believed that a majority of sexually active adults carry the herpes virus. Part of the reason for the continued high infection rate is that most women infected with the herpes virus do not know that they are infected because they have few or no symptoms. In many women, there are "atypical" outbreaks where the only symptom may be mild itching or minimal discomfort. Moreover, the longer the woman has had the virus, the fewer the symptoms they have with their outbreaks. Finally, the virus can be shed from the cervix into the vagina in women who are not experiencing any symptoms.

Symptoms of genital herpes

Once exposed to the virus, there is an incubation period that generally lasts 3 to 7 days before a lesion develops. During this time, there are no symptoms and the virus cannot be transmitted to others. An outbreak usually begins within two weeks of initial infection and manifests as an itching or tingling sensation followed by redness of the skin. Finally, a blister forms. The blisters and subsequent ulcers that form when the blisters break are usually very painful to touch and may last from 7 days to 2 weeks. The infection is definitely contagious from the time of itching to the time of complete healing of the ulcer, usually within 2 to 4 weeks. However, as noted above, infected individuals can also transmit the virus to their sex partners in the absence of a recognized outbreak.

Diagnosis of genital herpes

Genital herpes is suspected when multiple painful blisters occur in a sexually exposed area. During the initial outbreak, fluid from the blisters may be sent to the laboratory to try and culture the virus, but cultures only return a positive result in about 50% of those infected. In other words, a negative test result from a blister is not as helpful as a positive test result, because the test may be a false-negative test. However, if a sample of a fluid-filled blister (in the early stage before it dries up and crusts) tests positive for herpes, the test result is very reliable. Cultures taken during an initial outbreak of the condition are more likely to be positive for the presence of HSV than cultures from subsequent outbreaks.

There are also blood tests that can detect antibodies to the herpes viruses that can be useful in some situations. These tests are specific for HSV-1 or HSV-2 and are able to demonstrate that a person has been infected at some point in time with the virus, and they may be useful in identifying infection that does not produce characteristic symptoms. However, because false-positive results can occur and because the test results are not always clear-cut, they are not recommended for routine use in screening low-risk populations for HSV infection.

Other diagnostic tests such as polymerase chain reaction (PCR) to identify the genetic material of the virus and rapid fluorescent antibody screening tests are used to identify HSV in some laboratories.

Treatment of genital herpes

Although there is no known cure for herpes, there are treatments for the outbreaks. There are oral medications, such as acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex) that prevent the virus from multiplying and even shorten the length of the eruption. Although topical (applied directly on the lesions) agents exist, they are generally less effective than other medications and are not routinely used. Medication that is taken by mouth, or in severe cases intravenously, is more effective. It is important to remember that there is still no cure for genital herpes and that these treatments only reduce the severity and duration of outbreaks.

Since the initial infection with HSV tends to be the most severe episode, an antiviral medication usually is warranted. These medications can significantly reduce pain and decrease the length of time until the sores heal, but the treatment of the first infection does not appear to reduce the frequency of recurrent episodes.

In contrast to a new outbreak of genital herpes, recurrent herpes episodes tend to be mild, and the benefit of antiviral medications is only derived if therapy is started immediately prior to the outbreak or within the first 24 hours of the outbreak. Thus, the antiviral drug must be provided for the patient in advance. The patient is instructed to begin treatment as soon as the familiar pre-outbreak "tingling" sensation occurs or at the very onset of blister formation.

Finally, suppressive therapy to prevent frequent recurrences may be indicated for those with more than six outbreaks in a given year. Acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex) may all be given as suppressive therapies.

Herpes can be spread from one part of the body to another during an outbreak:

• It is important not to touch the eyes or mouth after touching the blisters or ulcers.
• Thorough hand washing is a must during outbreaks.
• Clothing that comes in contact with ulcers should not be shared with others.
• Couples that want to minimize the risk of transmission should always use condoms if a partner is infected. Unfortunately, even when an infected partner isn't currently having an outbreak, herpes can be spread.
• Couples may also want to consider avoiding all sexual contact, including kissing, during an outbreak of herpes.
• Since an active genital herpes outbreak (with blisters) during labor and delivery can be harmful to the infant, pregnant women who suspect that they have genital herpes should tell their doctor. Women who have herpes and are pregnant can have a vaginal delivery as long as they are not experiencing symptoms or actually having an outbreak while in labor.

What are HPVs?

More than 40 types of HPV, which are the cause of genital warts (also known as condylomata acuminate or venereal warts), can infect the genital tract of men and women. These warts are primarily transmitted during sexual contact. Other, different HPV types generally cause common warts elsewhere on the body. HPV infection has long been known to be a cause of cervical cancer and other anogenital cancers in women, and it has also been linked with both anal and penile cancer in men.

HPV infection is now considered to be the most common sexually transmitted infection in the US, and it is believed that a majority of the reproductive-age population has been infected with sexually transmitted HPV at some point in life.

HPV infection is common and does not usually lead to the development of warts, cancers, or specific symptoms. In fact, the majority of people infected with HPV have no symptoms or lesions at all. The ultimate test to detect HPV involves the identification of the genetic material (DNA) of the virus.

Of note, it has not been definitively established whether the immune system is able to permanently clear the body of an HPV infection. For this reason, it is impossible to predict exactly how common HPV infection is in the general population.

Asymptomatic people (those without HPV-induced warts or lesions) who have HPV infections are still able to spread the infections to others through sexual contact.

Diagnosis of HPV and genital warts

A typical appearance of a genital lesion may prompt the physician to treat without further testing, especially in someone who has had prior outbreaks of genital warts. Genital warts usually appear as small, fleshy, raised bumps, but they can sometimes be extensive and have a cauliflower-like appearance. They may occur in any sexually exposed area. In many cases, genital warts do not cause any symptoms, but they are sometimes associated with itching, burning, or tenderness.

HPV can sometimes be suspected by changes that appear on a Pap smear, although Pap smears were not really designed to detect HPV. In the case of an abnormal Pap smear, the clinician will often do advanced testing on the material to determine if, and which kind, of HPV, may be present. HPV can also be detected if a biopsy (for example, from a genital wart or from the uterine cervix) is sent to the laboratory for analysis.

How is HPV treated?

There is no cure or treatment that can eradicate HPV infection, so the only treatment is to remove the lesions caused by the virus. Unfortunately, even removal of warts does not necessarily prevent the spread of the virus, and genital warts frequently recur. None of the available treatments are ideal or clearly superior to others.

A treatment that can be administered by the patient is a 0.5% solution or gel of podofilox (podophyllotoxin). The medication is applied to warts twice per day for 3 days followed by 4 days without treatment. Treatment should be continued up to 3-4 weeks or until the lesions are gone. Podofilox may also be applied every other day for a total of 3 weeks. Alternatively, a 5% cream of imiquimod (a substance that stimulates the body's production of cytokines, chemicals that direct and strengthen the immune response) is likewise applied by the patient three times a week at bedtime and then washed off with mild soap and water 6-10 hours later. The applications are repeated for up to 16 weeks or until the lesions are gone. Sinecatechin 15% ointment, a green tea extract with an active product (catechins), is another topical treatment that can be applied by the patient. This drug should be applied three times daily until complete clearance of warts, for up to 16 weeks.

Only an experienced physician can perform some of the treatments for genital warts. These include, for example, placing a small amount of a 10% to 25% solution of podophyllin resin on the lesions, and then, after a period of hours, washing off the podophyllin. The treatments are repeated weekly until the genital warts are gone. An 80% to 90% solution of trichloroacetic acid (TCA) or bichloracetic acid (BCA) can also be applied weekly by a physician to the lesions. Injection of 5-fluorouracil epinephrine gel into the lesions has also been shown to be effective in treating genital warts.

Alternative methods include cryotherapy (freezing genital warts with liquid nitrogen) every one to two weeks, surgical removal of the lesions, or laser surgery. Laser surgery and surgical excision both require a local or general anesthetic, depending upon the extent of the lesions.

Treatment of precancerous changes (dysplasia) of the cervix related to HPV infection

Women who have evidence of moderate to severe precancerous changes in the uterine cervix require treatment to ensure that these cells do not become invasive cancer. In this case, treatment usually involves surgical removal or destruction of the involved tissue. Conization is a procedure that removes the precancerous area of the cervix using a knife, a laser, or a procedure known as LEEP (loop electrosurgical excision procedure, which uses an electric current passing through a thin wire that acts as a knife). Cryotherapy (freezing) or laser therapy may be used to destroy tissue areas that contain potentially precancerous changes.

What should a person do if sexually exposed to someone with genital warts?

Both people with HPV infection and their partners need to be counseled about the risk of spreading HPV and the appearance of the lesions. They should understand that the absence of lesions does not exclude the possibility of transmission and that condoms are not completely effective in preventing the spread of the infection. It is important to note that it is not known whether treatment decreases infectivity.

Finally, female partners of men with genital warts should be reminded of the importance of regular Pap smears to screen for cervical cancer and precancerous changes in the cervix, since precancerous changes can be treated and reduce a woman's risk of developing cervical cancer. Similarly, men should be informed of the potential risk of anal cancers, although it is not yet been determined how to best screen for or manage early anal cancer.

HPV vaccine

A vaccine is available against four common HPV types associated with the development of genital warts and cervical and anogenital carcinomas. This vaccine (Gardasil) has received FDA approval for use in males and females between 9 and 26 years of age.

What is chancroid?

Chancroid is an infection caused by the bacterium Hemophilus ducreyi, which is passed from one sexual partner to another. It begins in a sexually exposed area of the genital skin, most commonly the penis and vulva (the female external genital organs including the labia, clitoris, and entrance to the vagina). Chancroid starts out as a tender bump that emerges 3-10 days (the incubation period) after the sexual exposure. The cells that form the bump then begin to die, and the bump becomes an ulcer (an open sore) that is usually painful. Often, there is an associated tenderness and swelling of the glands (lymph nodes) in the groin that normally drain lymph (tissue fluid) from the genital area; however, the painful ulcer and tender lymph nodes occur together in only about one-third of infections. Chancroid is common in developing countries but is a relatively rare cause of genital ulcers in the U.S.

Diagnosis of chancroid

A clinical diagnosis of chancroid (which is made from the medical history and physical examination) can be made if the patient has one or more painful ulcers in the genital area and tests are negative for syphilis or herpes. (The word chancroid means resembling a chancre, the genital ulcer that is caused by syphilis. Chancroid sometimes is called soft chancre to distinguish it from the chancre of syphilis that feels hard to the touch. The ulcer of chancroid also is painful, unlike the ulcer of syphilis that is painless.) The diagnosis of chancroid can be confirmed by a culture of the material from within the ulcer for the bacterium Hemophilus ducreyi. The clinical diagnosis justifies the treatment of chancroid even if cultures are not available.

Treatment of chancroid

Chancroid is almost always cured with a single oral dose of azithromycin (Zithromax) or a single injection of ceftriaxone (Rocephin). Alternative medications are ciprofloxacin (Cipro) or erythromycin. Whichever treatment is used, the ulcers should improve within seven days. If no improvement is seen after treatment, the patient should be reevaluated for causes of ulcers other than chancroid. HIV-infected individuals are at an increased risk for failing treatment for chancroid and should be observed closely to assure that the treatment has been effective.

What should a person do if exposed to someone with chancroid?

A health care professional should evaluate anyone who has had sexual contact with a person with chancroid. Whether or not exposed individuals have an ulcer, they should be treated. Moreover, if the contact was 10 days or less before the onset of their partner's ulcer, they should be treated.

Picture of pubic louse (crab)

What are ectoparasitic infections?

Ectoparasitic infections are infections that are caused by tiny parasitic bugs, such as lice or mites. They are transmitted by close physical contact, including sexual contact. The parasites affect the skin or hair and cause itching.

Pubic lice (pediculosis pubis)

Pediculosis pubis is an infection of the genital area caused by the crab louse (Phthirus pubis). The lice (commonly called crabs) are small bugs that are visible to the naked eye without the aid of a magnifying glass or microscope. The lice live on pubic hair (or any other hair) and are associated with itching.

The treatment for pubic lice is usually with a 1% cream rinse of permethrin that is applied to the affected area and washed off after 10 minutes. Alternative treatments include pyrethrins with piperonyl butoxide applied for 10 minutes before washing off. None of these treatments should be used for involvement near the eyes because they can be very irritating. The patient's bedding and clothing should be machine-washed with hot water. All sexual partners within the preceding month should be treated for pubic lice and evaluated for other STDs.

Scabies

Scabies is an ectoparasitic infection caused by a mite (known as Sarcoptes scabiei) that is not visible with the naked eye but can be seen with a magnifying glass or microscope. The parasites live on the skin and cause itching over the hands, arms, trunk, legs, and buttocks. The itching usually starts several weeks after exposure to a person with scabies and is often associated with small bumps over the area of itching. The itching from scabies is usually worse at night.

The standard treatment for scabies is a 5% cream of permethrin (Elimite), which is applied to the entire body from the neck down and then washed off after 8 to 14 hours. Treatment is repeated in one week.

Ivermectin (Stromectol) is a drug taken by mouth that has also been successfully used to treat scabies. The CDC recommends taking this drug at a dosage of 200 micrograms per kilogram body weight as a single dose, followed by a repeat dose 2 weeks later. While a patient may find that taking a drug by mouth is more convenient than the application of the cream, ivermectin has a greater risk of toxic side effects than permethrin and has not been shown to be superior to permethrin in eradicating scabies.

An alternative treatment is 1 ounce of a 1% lotion or 30 grams of cream of lindane, applied from the neck down and washed off after approximately eight hours. Unfortunately, itching may persist for up to 2 months after successful therapy. Since lindane can cause seizures when it is absorbed through the skin, it should not be used if the skin is significantly irritated or wet, such as with extensive skin disease, rash, or after a bath. As an additional precaution, lindane should not be used in pregnant or nursing women or children younger than 2 years old.

As with pubic lice infection, both the bedding and clothing of an infected individual should be machine-washed in hot water. Finally, all sexual and close personal and household contacts within the month before the infection should be examined and treated if the infection is found.

What are HIV and AIDS?

Infection with the human immunodeficiency virus (HIV) weakens the body's immune system and increases the body's vulnerability to many different infections, as well as the development of certain cancers.

HIV is a viral infection that is primarily transmitted by sexual contact or sharing needles, or from an infected pregnant woman to her newborn. Negative antibody tests do not rule out recent infection. Most people who are infected will have a positive HIV antibody test within 12 weeks of exposure.

Symptoms of HIV and AIDS

Although there are no specific symptoms or signs that confirm HIV infection, many people will develop a nonspecific illness two to four weeks after they have been infected. This initial illness may be characterized by fever, vomiting, diarrhea, muscle and joint pains, headache, sore throat, and/or painful lymph nodes. On average, people are ill for up to two weeks with the initial illness. In rare cases, the initial illness has occurred up to 10 months after infection. It is also possible to become infected with the HIV virus without having recognized the initial illness.

• The average time from infection to the development of symptoms related to immunosuppression (decreased functioning of the immune system) is 10 years.
• Serious complications include unusual infections or cancers, weight loss, intellectual deterioration (dementia), and death.
• When the symptoms of HIV are severe, the disease is referred to as the acquired immunodeficiency syndrome (AIDS).
• Numerous treatment options now available for HIV-infected individuals allow many patients to control their infection and delay the progression of their disease to AIDS.

The most important fact to remember about sexually transmitted infections is that all of them are preventable. However, the risks of these infections are often downplayed and thus forgotten by many. The use of condoms can help decrease the risk of transmission of certain infections, but they do not prevent the transmission of many infections.

There is truly no such thing as safe sex. Sex in the context of a monogamous relationship wherein neither party is infected with an STD is, however, considered safe.

STDs in women can be treated by primary care providers, including:

• internists,
• family practitioners, and
• pediatricians.

In many cases, obstetrician-gynecologists treat STDs in women. For certain STDs, like HIV and hepatitis, other specialists may be consulted, including:

• immunologists,
• hepatologists, and
• gastroenterologists.

• STDs are infections that are transmitted during any type of sexual contact.
• Many STDs in women do not cause specific symptoms.
• Common STDs in women include chlamydia, gonorrhea, HPV, genital herpes, and the Zika virus.
• Antibiotic treatment can cure STDs caused by bacteria, including chlamydia, syphilis, and gonorrhea.
• No cure is available for some STDs like HIV or chronic hepatitis B infection, but medications are available to manage these chronic conditions.
• Complications of STDs depend upon the specific type of illness, but the pelvic inflammatory disease (PID) and infertility are complications of some STDs.
• Condoms can protect against some, but not all, STDs and are never 100% effective in protecting against STDs.