Q&A: ‘False sense of safety’ contributes to rise in STDs after menopause

Key takeaways:

• Misconceptions, lack of HPV vaccination and higher infection risk are tied to STD growth for women aged at least 55 years.
• OB/GYNs must ask all patients about their sexual history to test for and prevent STDs.

In the past decade, STDs have increased among women aged at least 55 years, highlighting the importance of discussing sexual partners, sexual history and condom use with all patients, regardless of age.

From 2010 to 2022, among U.S. women aged 55 years and older, gonorrhea cases rose from 443 to 2,684; chlamydia cases rose from 2,155 to 5,852; and primary and secondary syphilis cases rose from 41 to 578, according to CDC AtlasPlus data. Similar results were observed for men in the same age group.

“The false sense of safety characterizing both men and women in this 55-to-64-year-old category needs to be further enunciated that they’re not safe and they need to take precautions just like the 15-to-24-year-olds,” James A. Simon, MD, CCD, MSCP, IF, FACOG, medical director and founder of IntimMedicine Specialists, past-president of the International Society for the Study of Women’s Sexual Health and clinical professor at George Washington University, told Healio.

Healio spoke with Simon about the CDC data and about the rise and prevention of STDs among late middle-aged women.

Healio: CDC data demonstrated that gonorrhea, chlamydia and syphilis cases have grown rapidly since 2010 for men and women aged 55 years or older in the U.S. Why might that be?

Simon: There are a couple of caveats that are important. First, there’s no question that the rate of growth in that population is increasing. It’s not entirely clear to me if it’s increasing generally or over a relative lull during the COVID pandemic. I’m not contesting the fact that sexually transmitted infections in midlife women are going up and it’s important and needs to stop, but in terms of absolute numbers, it’s still a relatively small number compared with men and women aged 15 to 24 years. About half of all STIs still occur in the age 15-to-24 group. It’s not clear to me that that big increase in the rate is compared to the long-standing trend or the low that occurred during the pandemic, when rates went down for everybody because we were locked up at home and not having sex. Those are important caveats.

As it relates specifically to 55-to-64-year-old women, there are a number of important issues. The first is women that age are largely unvaccinated for HPV, which is an STI. In some countries around the world, vaccination is required for younger men and women, for example 15-to-24-year olds, in order to attend school, so they have very high rates of vaccination. Typically, people aged 55 to 64 years have not had vaccination. So that’s relatively important to the issue of HPV infection.

The more traditional infections — gonorrhea, chlamydia, syphilis, trichomoniasis, HIV — those infections are rising rapidly in this age group for a couple of specific reasons. One is that they don’t need contraception. They think, “I don’t need to use condoms in this interaction.” So, there’s no barrier form of STI protection. Younger men and women, because they’re worried about pregnancy, get STI prevention along with pregnancy prevention by using condoms.

Secondly, many women aged 55 years and older are not on any hormones, either systemic or vaginal and vulvar hormones. This puts their tissues, which are more friable and more easily traumatized, at increased risk for infection. In addition, there’s some data to suggest that the risk of infection is greater not only because of the tissue trauma or susceptibility to trauma, but also because there’s less lubrication during sexual contact, and that adds to the trauma to the tissues.

Finally, the tissues, either by age or increased susceptibility to trauma, might lose some of their ability to fight STIs. That’s an immunologic benefit of systemic and, to some degree, local hormones. So, we have a trifecta of factors that are associated with menopause and not using hormones that increase the risk for an STI, bacterial, viral,, etc, that younger women may not have.

Interestingly, men and women aged 55 years and older have also learned from younger men and women and they’re using apps to “hook up.” Not just to have relationships, but they’re using apps to hook up specifically for sex. Obviously, there are increased risks with this activity, when not using condoms.

Healio: What are the implications of increased STD reports among later middle-aged women?

Simon: In the context of routine gynecologic care or team care extending to the male partners, we need to be vigilant. We have to ask hard, direct questions. I’m a gynecologist by training, so I ask, “Are you sexually active with men, women or both?” When you ask a married woman in a stable, monogamous, heterosexual relationship that question, you might get some surprising answers. Believe me, I’ve heard them all multiple times for more than 4 decades. Not every person is completely monogamous, despite what we’d like to believe. Single men and women are also having more partners.

In this older age group, they’re not using protection, their immune systems and their tissues are altered. So, the increased risks for infection need to be ferreted out. They’re commonly attributed to other more common issues. For example, if a typical 55-to-60-year-old woman comes in and she’s complaining of vulvar burning, vaginal itching or vaginal discharge, the assumption is that she’s got a yeast infection. But, if you don’t find out that she also has three or four sexual partners, then you don’t go looking for an STI. You might treat her over Zoom, for example, for a yeast infection or a bladder infection, or whatever the appropriate symptoms suggest. But STIs can cause the exact same symptoms.

If you don’t find out that she’s sexually active, that she’s had a new partner, that she has multiple partners, or is swiping on apps to “hook up,” etc, you don’t find out that she’s at risk for an STI and it goes untreated and can possibly be transmitted to somebody else. So, we must ask, “Are you sexually active with men, women or both? Have you had any new sexual partners that might explain your symptoms?”

Further, we must check more than just their vaginas. For example, the availability of sexually explicit internet content for free has changed the prevalence and practice of many sexual activities which has been more traditional in this age group. Now, it’s not uncommon for a person to be having oral sex, manual sex, vaginal sex and anal sex. You may need to culture the anus in addition to the vagina, the throat or all three, to properly treat or diagnose the infection and the source thereof.

Healio: In addition to thinking condom use is unnecessary are there other misconceptions that contribute to the rise in STDs among this population?

Simon: There’s a subgroup of men and women that aren’t worried about these diseases because they figure they can be treated for them. By and large, these men and women aged 55 to 64 years came into their sexual being before there was much HIV disease and before a vaccine for HPV disease. The worst that they could get and not be treated for would have been herpes. So, maybe they’re like teenagers and think that they’re “immortal” in some way and they don’t need to worry about it because they can be treated, not realizing that some of these STIs can be with you for a lifetime and can significantly affect your overall health and certainly have an impact on your sexual health.

Healio: How can physicians promote the use of protection during intercourse and increase awareness and knowledge of STDs among menopausal and postmenopausal women?

Simon: We need to tell it like it is. We need to say, “You need to think about STIs. They’re on the rise, particularly in heterosexual activities, and you need to be careful. And, before you assume that because you can’t get pregnant, you can’t get an STI, we need to double check.”

I’m not suggesting that people are jumping into every Tom, Dick and Harry’s bed on the first date, but if it looks like it’s becoming serious enough to have sex, let’s get some testing done. Let’s get some testing on Tom or Dick or Harry, and make sure everybody’s whistle-stop clean from the get-go. Then we can throw away the condoms. But, until then, “no glove no love.”

Take precautions, take care of yourself and don’t be forced into anything you don’t want to do. Then let’s do some testing while you’re using condoms and make sure that if you’re going to continue to have sex with this person, that you’re monogamous, they’re monogamous and you’re both free of diseases before you throw away the condoms.

In addition, most health care professionals are younger than 55 years. Not all of them, but many of them. As humans, we don’t like to think about our parents or grandparents as having sex. Say your parents are probably still having sex and you think, “yuck, gross.” That comment is inherent in all of us. I think it’s universal. If we are a health care professional, and someone our parents’ or grandparents’ age is there, we don’t naturally think they’re having sex. So, we suppress or avoid talking about this subject because we have an inherent discomfort with the idea that our parents or grandparents were having sex. That could be another barrier to bringing it up, doing testing, etc.

Healio: Is there anything you’d like to add?

Simon: There’s a subgroup of men and women who are at particularly high risk for some difficult disorders, mainly HIV. There are bisexual men who have sex with men and then have sex with women, and they may or may not be out about that. That’s a subgroup that is at much higher risk for STIs, specifically HIV. Then there’s another group of both men and women who are IV drug users, and they are also at much higher risk for HIV. Their partners need to be careful about whether any interaction might be with a person who is HIV positive.

Another thing that is not typically counted in reports like the United States Preventive Services Task Force guidance on treatment or the new reports discussing midlife women and their risk for STIs, is that hepatitis is also an STI that needs to be tested for. We have tests for it, but it’s often either forgotten or put on the backburner as an out of sight out of mind and asymptomatic infection. It, too, is sexually transmitted and we need to make sure that everybody is tested for it. If someone has hepatitis or carries hepatitis, these days much of it can be cured, whereas in the past, it was a chronic, long-lasting or lifelong disorder.

For more information:

James A. Simon, MD, CCD, MSCP, IF, FACOG, can be reached at jsimon@intimmedicine.com.

Reference:

• CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) AtlasPlus. gis.cdc.gov/grasp/nchhstpatlas/charts.html. Published 2024. Accessed April 17, 2024.