Risk of Gonococcal Infection During Vaginal Exposure is Associated With High Vaginal pH and Active Menstruation

Abstract

Background.-An understanding of the biological reasons why 25%−35% of women resist infection during vaginal intercourse with a man infected with N. gonorrhoeae could lead to novel control measures. We sought modifiable biological bases for infection resistance by comparing women in the same core-mixing group who did or did not become infected after sexual exposure. Methods.-We enrolled 61 female contacts of index men with gonorrhoea seen at Baltimore City Health Department clinics from January 2008 through May 2012. Exposure and sexual practices and histories, co-infections, physical signs on exam, patient symptom report, and menstrual history were collected. Results.-Thirty-eight of the exposed women developed cervical infections (62.3%). Multiple logistic regression found that a vaginal pH ≥4.5 at presentation to clinic was significantly associated with gonococcal infection (adjusted odds ratio 5.5; p = 0.037) in women who presented within one menstrual cycle, 35 days. In this group of women, there was a significant association between acquiring an N. gonorrhoeae cervical infection and sexual exposure during menstruation (adjusted odds ratio 12.5; p = 0.05). Conclusions.-Modification of vaginal pH could be explored as novel strategy for reducing the risk of Neisseria gonorrhoeae infections in women.

Epidemiological and Clinical Observations of Gonococcal Infections in Women and Prevention Strategies

“…When we examined infection in the context of exposure relative to the menstrual cycle, we observed a noticeable difference in the phase of the menstrual cycle between exposed women who were infected and exposed women who were uninfected. This is in agreement with previous studies [ 16 , 23 , 24 ], which have shown that changes in the female body influenced by the variation in hormonal level during the menstrual period may favor the occurrence of STIs, including N. gonorrhoeae [ 25 ]. Use of oral hormone-based contraceptives were only reported by infected women as opposed to other types of birth control methods, including IUDs.…”

“…Among them, one was already in her menopause period and another one stated that her last menstrual period occurred 71 days before exposure to the infected man. A timeline of the women’s exposure to the infected men relative to the menstrual cycle phase [ 16 ] suggested that the majority of the uninfected women were exposed in the follicular phase, while exposure in any other cycle phase (ovulation or luteal phase) more frequently resulted in infection ( Figure 2 B).…”

“…Our demographic analysis indicated that risk of infection is not limited only to young adults with multiple and occasional sexual partners, and minorities with socioeconomic disadvantages, as shown in other cohorts [ 35 , 36 , 37 ]—a consideration which should be taken into account when planning population vaccination strategies. Despite the small size of our study compared to other studies [ 16 , 17 , 18 , 24 ], it presents a unique opportunity to analyze unique aspects of gonorrhea in exposed “asymptomatic” women, a population that is understudied because these individuals do not seek treatment. While some infected women may spontaneously clear the infection over time, by remaining undiagnosed and untreated, many could develop severe disease (PID) and associated consequences such as infertility or ectopic pregnancies [ 38 , 39 , 40 , 41 ].…”

How to Identify Exposed Women Who Are Infected with Neisseria gonorrhoeae

“…As N. gonorrhoeae acquires resistance to the currently recommended antimicrobials, enrolling women in treatment trials of newer agents is of great importance. However, N. gonorrhoeae cervical infections are asymptomatic in many women, cause nonspecific symptoms in others, and cannot be presumptively diagnosed with Gram stain of cervical secretions, as these have a strikingly low sensitivity (<0.1) [2]. This makes it difficult to conduct intervention trials.…”

Behavioral Effects of Different Contraceptive Methods and HIV Acquisition: An Ancillary Study of the ECHO* Randomized Trial

“…18 In addition, other studies have linked sexual exposure during menstruation with an increased risk of gonococcal infection. 20,21 Our nding of a tendency to a negative association between menstruation and HIV acquisition suggests that menstruation might be a protective factor for HIV acquisition, probably because women are less likely to engage in sexual intercourse during their menstrual periods and therefore have less sexual intercourse overall compared with women who do engage in intra-menstrual coitus. Women (and men) may intuitively feel more exposed to the risk of STI acquisition during menstruation and may prefer to avoid intra-menstrual coitus.…”