STD Awareness: Gonorrhea, Women, and the Pre-Antibiotic Era

Penicillin, the first cure for gonorrhea, was developed for mass production in the 1940s.

Penicillin, the first reliable cure for gonorrhea, was mass produced in the 1940s.

It’s Women’s History Month, a time to reflect on the achievements of women worldwide — like Margaret Sanger, Rosalind Franklin, and Florence Nightingale, or contemporary heroes like Wangari Maathai. But it may also be a time to examine some of the sadder aspects of womanhood, including the increased burden gonorrhea imposes on women. While gonorrhea is no picnic for anyone, it wreaks the most havoc in female reproductive tracts. In fact, before antibiotics, gonorrhea was a leading cause of infertility — one 19th century physician attributed 90 percent of female infertility to gonorrhea. Not only that, but the effects of gonorrhea could seriously reduce a woman’s overall quality of life.

With gonorrhea becoming more resistant to antibiotics, the CDC warns of a return to the pre-antibiotic era.

Gonorrhea is described by written records dating back hundreds of years B.C. Ancient Greeks treated it with cold baths, massage, “cooling” foods, and vinegar. In the Middle Ages, Persians might have recommended sleeping in a cool bed with a metal plate over the groin. A bit to the west, Arabs tried to cure gonorrhea with injections of vinegar into the urethra. Kings of medieval England might have had their gonorrhea treated with injections of breast milk, almond milk, sugar, and violet oil.

Although gonorrhea is as ancient an STD as they come, because women rarely have symptoms while men usually do, for much of history it was mostly discussed in terms of men. The name gonorrhea itself derives from the ancient Greek words for “seed flow” — gonorrhea was thought to be characterized by the leakage of semen from the penis. This confusion inspired many misguided notions throughout the millennia, such as the idea that almost all women carried gonorrhea and transmitted it to their unwitting male partners.

This illustration from a 1913 medical textbook shows the effects of gonorrhea on the uterus, fallopian tubes, and ovaries. They are thickened, inflamed, and contain cysts.

It was relatively recently in our history that gonorrhea’s significance in the female population became widely recognized. In the 1870s, we realized that gonorrhea could, after a period of latency, cause inflammation of the uterus and fallopian tubes, which could eventually lead to infertility. We also discovered gonococci, the bacteria that cause gonorrhea. Back then, however, today’s STD tests didn’t exist — according to a 1905 medical journal, even after gonococci’s discovery, it wasn’t always easy to find them under a microscope. By the 1920s, doctors could extract pus and discharge from female patients and examine it under a microscope, but this procedure could be uncomfortable or painful, as the urethra would have to be “milked” and pus would be taken from the Skene’s and Bartholin glands — which required much pressure and force. These procedures might have to be repeated multiple times for a more accurate diagnosis.

Furthermore, women rarely experienced initial gonorrhea symptoms, allowing the infections to inflict serious and permanent damage before being discovered. When gonorrhea had spread deep into the reproductive tract — known as pelvic inflammatory disease — painful symptoms could ensue. Untreated gonorrhea could cause the fallopian tubes to fill with pus and form permanent masses, and inflammation of the reproductive organs could lead to unpleasant or debilitating symptoms. In extreme cases, the uterus, fallopian tube, or ovary might be surgically removed — and, in the pre-antibiotic era, surgery was riskier. Less major surgical procedures included removing or cauterizing certain glands.

By the early 20th century, gonorrhea was recognized as coming in two forms: “acute” and “chronic.” It was thought that an acute infection could be treated with topical medications, and lasted for one to two weeks after the infection was first acquired. A chronic infection, after becoming established, had advanced farther up the reproductive tract and burrowed below the skin’s surface where it could avoid antiseptics. The “chronic” form could lead to painful menstruation, “pelvic distress,” and, ultimately, infertility. Female prostitutes, who were at increased risk for repeated infections, were known to have high rates of infertility. However, all sexually active women were vulnerable: According to a physician writing in 1905, cases of infertility “are but too often seen in young women a year or less after marriage,” implying that gonorrhea was usually contracted from their new husbands — one estimate held that 10 percent of married men had gonorrhea when they wed.

Gonococci, we found, didn’t just cause infertility. During vaginal delivery, they can infect an infant’s eyes to cause ophthalmia neonatorum, which can lead to blindness. Ophthalmia neonatorum was very common before 1881, at which time we learned to put silver nitrate in newborns’ eyes to prevent infection.

A 1913 medical textbook estimated that 5 to 10 percent of pregnant women had gonorrhea, and back then ophthalmia neonatorum was still a leading cause of blindness. Home births were especially risky, as midwives didn’t administer silver nitrate. While their patients were still pregnant, obstetricians would attempt to disinfect the cervix — which might inadvertently induce abortion. Before labor, they might have painted their patients’ external genitalia, vagina, and cervix with an iodine solution, or administered an antiseptic douche in the hopes of washing away bacteria that might otherwise colonize the infant’s eyes. To prevent the solution from entering the uterus, specialized douche nozzles shot liquid out of the sides, and cotton was inserted against the cervix.

These practices were common before we learned that douching can cause more harm than good — although we recognized that condoms were “an almost certain means of prevention,” douching was advised immediately “after a suspicious intercourse” while almost no attention was given to condoms. Instead, “moral” changes were emphasized: abstinence, temperance, and cleanliness. By upholding douches and downplaying condoms, the responsibility for gonorrhea was placed on female shoulders.

A WWII-era government poster blames women for STD transmission.

By World War I, the focus had shifted back to men, in whom STDs were the No. 1 cause of disability in the military. Women were returned to the role of scapegoat: “A German bullet is cleaner than a whore,” U.S. soldiers were told, typical of government propaganda that cast women as “vectors.” In fact, attempts to quarantine women thought to be “spreaders” of STDs resulted in more than 20,000 female detainees being held in camps.

Physicians around the turn of the century sought to cure gonorrhea with medicines made from metallic compounds like arsenic, bismuth, and mercury. After World War I, physicians continued to seek cures. One medical journal article published in 1931 reports the use of radium in treating certain gonorrheal infections, but by the early 1930s, a hot new method was gaining popularity.

fever therapyFever therapy involved a contraption called a “fever cabinet,” which enclosed the patient’s body but not the head. Typically, the cabinet was kept at a humid 110 degrees Fahrenheit, which induced alarmingly high internal temperatures in patients, whose vital signs were monitored over 10-hour sessions. Based on the idea that heat could cure gonorrhea, some researchers went a step further and devised instruments, heated as high as 120 degrees, that could be inserted into the vagina and rectum and left in place for two hours. Fever therapy could be dangerous, and while some claimed cure rates as high as 87 percent, others claimed it was useless.

Luckily, the pre-antibiotic era was about to come to a close courtesy of two pharmacological breakthroughs. In the 1930s, a German chemist developed the first sulfa drugs, and in 1943, the U.S. military started to investigate penicillin. By the late 1940s and into the 1950s, public health officials began to wonder if gonorrhea would become a memory of a bygone era. “As a result of antibiotic therapy, gonorrhea has almost passed from the scene as an important clinical and public entity,” wrote Dr. John Mahoney of the U.S. Public Health Service in 1949.

Unfortunately, gonococci turned out to be wilier than many of us anticipated — they readily evolved resistance to the drugs we used to kill them. Ever increasing doses of sulfa drugs were required — sometimes, they were used in combination with fever therapy to boost efficacy. And, while penicillin was initially very effective, resistance was reported as early as 1946. This is evolution in action — by the 1970s, gonococci had fully adapted to their newly penicillin-drenched environment and emerged impervious to the drug. Over the decades, they continued to develop resistance to most of the other antibiotics we used.

Just last September, the Centers for Disease Control and Prevention classified antibiotic-resistant gonorrhea as an “urgent threat,” and predicted that failing to meet this challenge might throw us back into the pre-antibiotic era, during which gonorrhea was incurable and wreaked havoc on our reproductive systems. Because women bear the brunt of gonorrhea’s disease burden, this development is especially of concern to those of us who care about women’s sexual and reproductive health. Safer sex is still of the utmost importance, as is antibiotic stewardship and pharmaceutical research.

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