Gonorrhea and Salpingitis among American Teenagers, 1960-1981

Laurene Mascola, M.D., M.P.H. Willard Cates, Jr., M.D., M.P.H. Gladys H. Reynolds, Ph.D. Joseph H. Blount, M.P.H.

Division of Venereal Disease Control Center for Prevention Services William L. Albritton, M.D., Ph.D.

Sexually Transmitted Diseases Laboratory Program Center for Infectious Diseases Introduction In the past two decades, many American teenagers have participated in the so-called "sexual revolution." By 1979, teenagers were engaging in sexual activity at a greater frequency and at an earlier age than they had in the early 1970s (1). Consequently, the medical community became increasingly concerned with the health consequences of teenage sexuality, including sexually transmitted infections and pelvic inflammatory disease (PID). The following report outlines age-specific gonorrhea rates for U.S. teenagers in the period 1960-1981 and age-specific PID hospitalization rates for the same group in the period 1970-1980. Materials and Methods Age- and sex-specific gonorrhea rates for persons 10-19 years of age were obtained from data reported by year to the Division of Venereal Disease Control, CDC, from the 63 sexually transmitted disease (STD) project areas in the United States. Data from the Hospital Discharge Survey from the National Center for Health Statistics were used to calculate rates at which females ages 15-19 years were hospitalized with salpingitis (2). The Hospital Discharge Survey provides national estimates of the frequency of diagnoses among patients discharged from approximately 7,500 short-stay hospitals in the United States. Not enough data on hospitalization rates for females 10-14 years of age with PID were available for proper analysis. Results Temporal Patterns of Gonorrhea among Teenagers. Beginning in the early 1960s, the annual number of reported cases of gonorrhea among teenagers increased dramatically, peaking at approximately 276,000 cases in 1975. Thereafter, the number of reported cases declined slightly, although the age- and sex-specific rates remained stable (Table 1, Figures 1 and 2). Since 1975 over 250,000 cases of gonorrhea have been reported among U.S. teenagers; nearly 60% of these patients were female. Over the last two decades, gonorrhea rates for older teenagers have been persistently higher than those for younger teenagers (Figures 1 and 2). However, within the two age groups, the gender patterns differ. In the 10- to 14-year age group, rates for females were higher than those for males in the 1960s, and rates for females have risen faster than those for males, particularly in the early 1970s. In the 15- to 19-year age group, gonorrhea rates were higher for males (Figure 2). However, as of 1966, the gonorrhea rate for females in this age group began to rise faster than the rate of their male counterparts. By 1973, the gonorrhea rate for older teenage females overtook that for their male counterparts and remained higher through 1981. From 1960 to 1970 the rate at which females had gonorrhea tripled, while the rate for males increased twofold. For all teenage females, the gonorrhea rates have been quite stable since 1975, i.e., approximately 75 cases/100,000 females ages 10-14 years (Figure 1) and 1,400 cases/100,000 females ages 15-19 years (Figure 2). Among males in the older age group, the gonorrhea rate decreased slightly beginning in 1976, and in 1978 fell below 1,000 cases/100,000 males ages 15-19 years. Among younger teenage males, the gonorrhea rate increased through 1977, but declined thereafter. In other words, in 1981 for every 1,000 males ages 15-19 years, nine cases of gonorrhea were reported; the same year, for every 1,000 females ages 15-19 years, 14 gonococcal infections were reported. Temporal Patterns of Salpingitis among Teenagers. The total number of persons ages 15-19 years hospitalized with PID peaked in 1977 at nearly 47,000 cases (Table 2). After that, the number of hospitalized cases declined slightly, with 44,669 cases reported in 1980 (70% of which were among whites). After 1977, the rate of hospitalization for PID stabilized (Figure 3). In summary, the rates of both gonorrhea and hospitalization for PID for American teenagers ages 15-19 years rose in the early 1970s and later stablized (the rate for gonorrhea, around the mid 1970s and that for PID 1-2 years later). Discussion The two data sets presented in this report were obtained from different reporting sources. Data on gonorrhea are for patients attending either public clinics or private physicians' offices. However, most people with sexually transmitted disease (STD) go to public clinics where reporting is more complete, so the reporting is biased to some degree (2). Data on PID reflect all hospitalized patients in non-government hospitals in the United States, but are less specific than those for gonorrhea in that the former include cases caused by gonococcal and nongonococcal organisms such as Chlamydia. Gonorrhea is the most commonly reported communicable disease in the United States (3). In 1981, over 250,000 cases of gonorrhea were reported among U.S. teenagers. The actual number of infections probably exceeds the number reported by at least twofold; thus, U.S. teenagers have an estimated one-half million cases of gonorrhea each year (2). At these rates, it is projected that in 1983 approximately one of every 61 female teenagers will contract gonorrhea. In 1981, nearly 60% of all reported cases of gonorrhea among teenagers were in females. However, among persons more than or equal to 20 years of age, males accounted for approximately 60% of cases (4). Several factors have influenced the number, rates, and sex distribution of reported gonorrhea cases and the most serious complication of this infection, salpingitis, among American teenagers during the past two decades. First, the 1960s and 1970s were marked by the passage of the "baby-boom babies" through their teenage years (5). This bulge in the age pyramid had a dramatic effect on the number of STDs as well as on many other diseases. Second, during this era, teenagers became more sexually active (1). The likelihood that teenage females had experienced premarital sexual intercourse rose from 30% in 1971 to 50% in 1979. In addition, teenagers began sexual activity earlier and used contraceptive methods that were not effectively protective against lower genital tract infection (1). Third, in 1973, federally assisted state and local programs to control gonorrhea were implemented. Efforts focused on screening females from high-risk populations through culture analysis and encouraging infected male patients to bring or refer their sexual partners for medical care (6). A likely result of these case-detection activities was that the proportion of reported cases of gonorrhea among teenage females would rise. Indeed, by 1973, in the 15- to 19-year age group, the gonorrhea rates for females surpassed those for males. Fourth, in the period 1968-1971, various states passed laws permitting physicians to treat teenagers for STDs without notifying their parents (7). This might have contributed in part to the sustained rise in gonorrhea from 1968 to 1972. On the other hand, whereas gonorrhea among teenage females continued to rise through 1975, gonorrhea among teenage males actually started to decrease in 1970. Numbers of cases of PID for which patients were hospitalized, which would not be influenced by these laws, continued to rise through 1977. The continuing high incidence of salpingitis among young females bodes ill for the future. PID not only creates short-term risks but also can lead to infertility (due to scarring of fallopian tubes), ectopic pregnancy, chronic pelvic pain, dyspareunia, pelvic adhesions, pyosalpinx and tubo-ovarian abscesses. It has been estimated that 12%-20% of females with untreated gonorrhea will eventually develop salpingitis (8). Moreover, because of unique biologic characteristics and/or sexual and social behavior, young females may be even more susceptible than older females to upper genital tract infection (9,10). First, the younger females are more likely to delay seeking health care. Second, they are less likely to comply with a prescribed course of treatment. Finally, health-care providers are more likely to misdiagnose various abdominal complaints among adolescents. In light of the effect of serious sequelae on the potential future reproductive health of young females, physicians should always include acute salpingitis in their differential diagnosis of acute abdominal pain among adolescent females. Improperly diagnosed or treated STDs among adolescents can lead to smoldering infections that continue to be spread in this age group. With proper awareness, diagnosis, treatment, sexual-partner follow up and surveillance, high gonorrhea rates among teenagers can be reduced and serious sequelae prevented.

References

1. Zelnik M, Kantner JF. Sexual activity, contraceptive use, and pregnancy among metropolitan-area teenagers: 1971-1979. Fam Plann Perspect 1980;12:230-7.

2. Eisenberg MS, Wiesner PJ. Reporting and treating gonorrhea: results of a statewide survey in Alaska. J Am Ven Dis Assoc 1976:3;79-83.

3. CDC. Annual summary 1980: reported morbidity and mortality in the United States. MMWR 1981;29:3,5,10-17,34-8.

4. CDC. STD statistical letters, 1965-1981. Atlanta, Ga.: Centers for Disease Control, 1982.

5. Jones L. Great expectations: America and the baby-boom generation. New York: Coward, McCann, and Geoghegan, 1980.

6. Brown ST, Wiesner PJ. Problems and approaches to the control and surveillance of sexually transmitted agents associated with pelvic inflammatory disease in the United States. Am J Obstet Gynecol 1980;138:1096-1100.

7. CDC. Venereal disease control laws summary (00-3553). Atlanta, Ga.: Centers for Disease Control, 1979.

8. Wiesner PJ, Thompson SE. Gonococcal diseases. DM 1980;26(5);6-10.

9. Bell TA, Hein K. Adolescents and sexually transmitted diseases. In Holmes KK, Mardh P-A, Sparling PF, Wiesner PJ, eds. Sexually transmitted diseases. New York: McGraw Hill (in press).

10. Ostergard DR. The effect of age, gravidity, and parity on the cervical squamocolumnar junction as determined by colposcopy. Am J Obstet Gynecol 1977;129:59-63.

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