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
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CDC. Annual summary 1980: reported morbidity
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Jones L. Great expectations: America and the
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Brown ST, Wiesner PJ. Problems and approaches
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J Obstet Gynecol 1980;138:1096-1100.
CDC. Venereal disease control laws summary
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Ostergard DR. The effect of age, gravidity, and parity on
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colposcopy. Am J Obstet Gynecol 1977;129:59-63.
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