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Sexually Transmitted Infections in Women

STIs in women encompass a broad range of pathogens (chlamydia, gonorrhea, syphilis, trichomoniasis, genital herpes, HPV, and Mycoplasma genitalium), with distinct screening, diagnostic, treatment, and prevention considerations. Approximately 1 in 5 U.S. adults had an STI in 2018, but subsequent trends differ by infection; CDC provisional 2024 data show declining reported adult chlamydia, gonorrhea and primary/secondary syphilis, with congenital syphilis still increasing.[1][31]

Screening Recommendations​

The USPSTF recommends screening sexually active women ≤24 years and older women with risk factors for chlamydia and gonorrhea; the CDC recommends annual screening in those groups (risk factors include new or multiple partners, a partner with an STI, or inconsistent condom use outside a mutually monogamous relationship).[2][3] Additional screening points:

  • Syphilis. CDC geographic screening guidance offers testing to sexually active people aged 15–44 in counties where primary/secondary syphilis among women aged 15–44 exceeds 4.6 per 100,000; assess individual risk in other settings.[32] ACOG 2024, reaffirmed 2025, recommends screening every pregnant patient at the first prenatal visit, in the third trimester and at birth.[4][5][32][33]
  • HIV. Screen at least once at ages 15–65 years; screen higher-risk groups, including sexually active MSM, at least annually.[7][6]
  • Hepatitis B and C. Screen adults aged ≥18 once for HBV with HBsAg, anti-HBs and total anti-HBc; retest susceptible patients with ongoing exposure risk and screen HBsAg in each pregnancy. Screen adults once for HCV and during each pregnancy, except in settings with HCV RNA positivity <0.1%.[43][44]
  • Trichomoniasis. Consider testing asymptomatic women at high risk or in high-prevalence settings; annual screening recommended for women with HIV.[8][9]
  • Extragenital screening. Pharyngeal and rectal NAAT testing should be considered in women based on sexual practices and shared decision-making, as urogenital-only testing misses a substantial proportion of infections.[3]

Diagnosis​

Nucleic acid amplification tests (NAATs) are the preferred diagnostic method for chlamydia, gonorrhea, trichomoniasis, and M. genitalium, with sensitivities of 86–100% and specificities of 97–100%.[1] For urogenital NAATs in women, clinician- or self-collected vaginal swabs are preferred.[10] When discharge or postcoital bleeding suggests cervicitis, examine for mucopurulent endocervical discharge or contact bleeding, assess for PID, obtain gonorrhea/chlamydia NAATs, and evaluate for bacterial vaginosis and trichomoniasis.[6]

  • Syphilis relies on serologic testing using a sequential algorithm (treponemal followed by nontreponemal, or vice versa). Early infection can be seronegative; compatible lesions or exposure require clinical assessment, repeat testing and treatment when indicated rather than reassurance from an early negative result.[4][1]
  • Genital herpes. Use lesion NAAT/PCR when lesions are present. Reserve type-specific serology for appropriate indications; confirm low-positive HSV-2 immunoassay results with a second method. Routine serologic screening of asymptomatic patients is not recommended.[11][12]
  • M. genitalium. FDA-cleared NAATs are available; test women with recurrent cervicitis and consider testing in PID; do not routinely screen asymptomatic patients.[1][13]

Treatment​

The 2021 CDC STI Treatment Guidelines introduced several updates. For cervicitis in patients at increased STI risk, with unreliable follow-up or unavailable NAAT, start presumptive chlamydia treatment and add gonorrhea coverage according to individual and local risk; lower-risk patients may await test results.[6] For women at STI risk with pelvic or lower-abdominal pain and no alternative cause, the CDC recommends presumptive PID treatment when cervical-motion, uterine, or adnexal tenderness is present; a negative cervical gonorrhea/chlamydia test does not exclude upper-tract infection.[6] The table summarizes uncomplicated infection regimens in nonpregnant adults unless stated. Pregnancy, PID, neurologic/ocular syphilis, disseminated infection and treatment failure require their specific pathways.[6]

InfectionFirst-line RegimenNotes
ChlamydiaDoxycycline 100 mg PO BID × 7 dNonpregnant patients; pregnancy regimen below
GonorrheaCeftriaxone 500 mg IM × 1 (1 g if ≥150 kg)Treat chlamydia if not excluded; use pregnancy-appropriate therapy
Early syphilisBenzathine penicillin G 2.4 million U IM × 1Penicillin only therapy in pregnancy; desensitize if allergic
Late latent syphilis or unknown durationBenzathine penicillin G 2.4 million U IM weekly × 3
Trichomoniasis (women)Metronidazole 500 mg PO BID × 7 d7-day regimen preferred in women; comparable randomized evidence in men is lacking
Genital herpesFirst episode: valacyclovir 1 g PO BID × 7–10 d; recurrent HSV-2 suppression: valacyclovir 500 mg or 1 g PO dailyAcyclovir and famciclovir are alternatives with different regimens; 500 mg daily may be less effective with ≥10 recurrences/year. Suppression reduces frequent HSV-2 recurrences by 70–80%; transmission benefit depends on regimen and population.[6]
M. genitalium (macrolide-sensitive)Doxycycline 100 mg BID × 7 d → azithromycin 1 g once, then 500 mg daily × 3 dResistance-guided; not azithromycin 1 g alone
M. genitalium (macrolide-resistant / unknown)Doxycycline 100 mg BID × 7 d → moxifloxacin 400 mg daily × 7 dMacrolide-resistance markers range from 44–90% in the United States, Canada, Western Europe and Australia[6]
Mild-to-moderate PID, outpatientCeftriaxone 500 mg IM (1 g if >150 kg with documented gonorrhea) + doxycycline 100 mg BID × 14 d + metronidazole 500 mg BID × 14 dMetronidazole routinely included[6][41]

December 2025 FDA update: oral zoliflodacin (Nuzolvence) and gepotidacin (Blujepa) have indications for uncomplicated urogenital gonorrhea; pharyngeal gonorrhea, PID and disseminated disease are outside these indications. Blujepa's gonorrhea indication is limited to patients with few or no alternatives. Eligibility, pregnancy/reproductive precautions and interactions differ; consult their current labels rather than substituting these for ceftriaxone automatically.[34]

Treatment highlights:

  • Chlamydia. Doxycycline 100 mg twice daily for 7 days is now preferred over azithromycin, based on superior efficacy particularly at rectal sites.[9][7]
  • Gonorrhea. Ceftriaxone 500 mg IM single dose (1,000 mg if ≥150 kg); add antichlamydial treatment when chlamydia has not been excluded (doxycycline for nonpregnant patients; pregnancy-specific regimen below).[9][8]
  • Syphilis. Benzathine penicillin G 2.4 million units IM: single dose for early syphilis, weekly × 3 for late latent. Penicillin is the only recommended therapy for syphilis in pregnancy; evaluate a reported penicillin allergy, and desensitize patients with confirmed allergy before penicillin treatment.[4][1][6]
  • Trichomoniasis in women. Metronidazole 500 mg twice daily for 7 days (the 7-day regimen is superior to a single 2 g dose in women; randomized comparisons of these regimens in men are lacking).[9][8]
  • Genital herpes. Acyclovir, valacyclovir, or famciclovir for episodic and suppressive therapy. Suppression reduces frequent HSV-2 recurrences by 70–80%; daily valacyclovir reduces transmission in studied discordant heterosexual couples.[11]
  • M. genitalium. Resistance-guided sequential therapy: doxycycline 100 mg twice daily for 7 days, followed by azithromycin 1 g once then 500 mg daily for 3 days (if macrolide-sensitive) or moxifloxacin 400 mg daily for 7 days (if macrolide-resistant or unknown).[6] For M. genitalium-associated PID, moxifloxacin is given for 14 days; standard PID regimens do not reliably eradicate it. Seek specialist guidance in pregnancy or when resistance/contraindications limit options.[1][6]
  • PID. For eligible outpatients, give ceftriaxone 500 mg IM (1 g if >150 kg with documented gonorrhea) plus doxycycline 100 mg twice daily for 14 days and metronidazole 500 mg twice daily for 14 days.[6][41] Test for gonorrhea, chlamydia, HIV and syphilis, and arrange evaluation, testing, and presumptive gonorrhea/chlamydia treatment for partners who had sexual contact in the 60 days before symptom onset.[41] Hospital assessment is indicated when a surgical emergency cannot be excluded, in pregnancy, with tubo-ovarian abscess or severe illness, when outpatient treatment cannot be followed or tolerated, or after no clinical response to oral therapy within 72 hours.[9][14][41]

Retest treated women with chlamydia, gonorrhea or trichomoniasis at 3 months. This differs from test of cure: obtain chlamydia NAAT approximately 4 weeks after treatment in pregnancy, and test of cure 7–14 days after treatment for pharyngeal gonorrhea. Ensure partner evaluation/treatment and abstinence until the applicable regimen and interval are completed.[6][7]

Complications in Women​

Untreated STIs carry significant reproductive consequences. The numerical estimates below come from historical cohorts/reviews and vary with population, ascertainment and treatment:

  • Pelvic inflammatory disease (PID). In high-risk settings, 2–5% of untreated women developed PID in the roughly 2 weeks between a positive chlamydia test and treatment; rates in general asymptomatic populations followed for longer appeared low.[19] C. trachomatis is the most common identified pathogen (about 23% of PID cases).[15][14]
  • Infertility. In a historical cohort with laparoscopically verified PID, confirmed tubal-factor infertility occurred in 141/1,309 women (10.8%) who attempted conception; risk rose with the number and severity of PID episodes.[38] Most women with tubal factor infertility have no known history of PID but are seropositive for C. trachomatis.[15][16] In the largest studies reviewed by Haggerty and colleagues, up to 18% of women developed infertility after symptomatic PID of any cause.[19]
  • Ectopic pregnancy. In Weström and colleagues' historical Swedish cohort with laparoscopically verified PID, 9.1% of first pregnancies after index laparoscopy were ectopic, versus 1.4% after a normal laparoscopy.[15][38]
  • Chronic pelvic pain. Reported 3× more frequently in women with a history of PID (18% versus 5%).[15]
  • Adverse pregnancy outcomes. Among babies born to women with untreated syphilis, approximately 40% may be stillborn or die of infection as newborns.[39] U.S. congenital syphilis cases increased 106% from 2019 to 2023.[4] Chlamydia and gonorrhea are associated with preterm delivery, PPROM, and neonatal ophthalmia.[4][17]
  • Repeat chlamydial infections are associated with increased risk of PID and reproductive sequelae.[18][19]

STIs During Pregnancy: Screening, Treatment, and Complications​

InfectionScreening ScheduleTreatment in PregnancyMaternal / Fetal Complications
SyphilisFirst prenatal visit, third trimester, delivery (ACOG universal schedule)[33]Stage-specific benzathine penicillin G; desensitize if allergic. For early syphilis, a second 2.4-million-unit IM dose may be given after 1 week; in late-latent disease, repeat the full course if a weekly interval exceeds 9 days.[6]With untreated maternal syphilis, approximately 40% of babies can be stillborn or die of infection as newborns.[39] U.S. congenital syphilis cases increased 106% from 2019 to 2023.[4]
HIVFirst prenatal visit for all; repeat in the third trimester before 36 weeks if HIV acquisition risk is high[6]Antiretroviral therapyVertical transmission
Hepatitis BHBsAg during each pregnancy, preferably in the first trimesterIf HBsAg positive, check HBV DNA to guide maternal antiviral prophylaxis; give the infant HBIG and HepB vaccine within 12 hours of birth.[42]Vertical transmission
Hepatitis CEach pregnancy, except where HCV RNA positivity is <0.1%[6]Recheck HCV RNA after delivery and link to DAA care if viremia persists.[45]Vertical transmission
ChlamydiaFirst prenatal visit if aged <25 or older with risk factors; repeat in the third trimester if aged <25 or risk persists[6]Azithromycin 1 g orally once; test of cure at ~4 wkPreterm delivery, PPROM, neonatal ophthalmia
GonorrheaFirst prenatal visit if aged <25 or older with risk factors; repeat in the third trimester if aged <25 or risk persists[6]Ceftriaxone 500 mg IM once (1 g if ≥150 kg); add pregnancy-appropriate chlamydia treatment if infection is not excluded.[6]Preterm delivery, neonatal ophthalmia
TrichomoniasisTest if symptomatic; screen pregnant women with HIV at the first prenatal visit. Routine screening benefit in asymptomatic pregnancy is unestablished.[6]MetronidazolePPROM, preterm delivery

Prevention​

HPV Vaccination​

The 9-valent HPV vaccine (Gardasil 9) targets HPV types responsible for about 90% of HPV-attributable cancers worldwide and about 90% of HPV-positive invasive cervical cancers in an international tissue series; it is the only HPV vaccine available in the U.S.[20][21][40]

  • Routine vaccination. CDC recommends age 11–12, with initiation permitted at 9.[35] Catch up through 26 if incomplete: two doses when started before 15; three doses when started at 15 or older, and for immunocompromised patients regardless of younger starting age.[35][20][22] Defer initiation or remaining HPV vaccine doses during pregnancy and complete the series afterward.[35]
  • Ages 27–45. Shared clinical decision-making for previously unvaccinated individuals.[23][24]
  • Population-level impact. Cervical cancer incidence has declined about 69% in women aged 20–24, the first cohorts offered the vaccine; CIN3 declined 34% in ages 15–19.[22]
  • Screening recommendations apply regardless of vaccination status.[25]

Doxycycline Post-Exposure Prophylaxis (Doxy-PEP)​

Doxy-PEP (200 mg within 72 hours of condomless sex) reduced syphilis and chlamydia infections by more than 70% and gonococcal infections by about 50% in three randomized trials among MSM and transgender women.[26][27] However, the CDC recommends counseling and offering doxy-PEP through shared decision-making to MSM and transgender women with a bacterial STI in the past 12 months; it also permits discussion with some without a prior-year STI and gives no recommendation for cisgender women because evidence is insufficient.[27] The Kenyan randomized trial (women aged 18–30 taking HIV PrEP; RR 0.88, 95% CI 0.60–1.29) found no significant benefit; doxycycline was detected in only 29% of tested hair samples.[28] Low adherence is a possible explanation. Maximum dosing is 200 mg per 24 hours.[27][28]

Other Prevention Strategies​

  • Consistent condom use provides moderate protection (HR 0.70 for HSV-2 transmission).[12]
  • Expedited partner therapy is legal in most states; for chlamydia, offer it when partners from the preceding 60 days are unlikely to receive timely treatment, and for gonorrhea, offer it when timely evaluation remains unlikely after linkage efforts.[7][6]
  • Behavioral counseling is recommended for all adolescents and adults at increased STI risk.[14]

Special Populations​

  • Pregnancy. Universal screening for HIV, syphilis, and hepatitis B; screen for hepatitis C during each pregnancy except where HCV positivity is <0.1%; chlamydia/gonorrhea screening depends on age and risk.[6] Syphilis screening should occur at least 3 times during pregnancy.[7][5]
  • Women with HIV. Screen for gonorrhea, chlamydia, and syphilis at entry to care, then at least annually if asymptomatic and sexually active; screen for trichomoniasis at entry and at least annually in those who have receptive vaginal sex. For those with multiple or anonymous partners, screen every 3–6 months according to sexual activities, recent STIs in the patient or partners, and local STI prevalence.[8]
  • Adolescents. At highest risk for chlamydia and gonorrhea; provide confidential, developmentally appropriate care under applicable local consent rules.[7]
  • Women who have sex with women. Screen according to anatomy, exposures and applicable age/risk recommendations.[7]
  • Transgender men and gender-diverse patients on testosterone who retain a vagina. In a cross-sectional comparison, 28 transgender men prescribed testosterone for at least 1 year had lower Lactobacillus dominance and higher vaginal microbial diversity than 8 cisgender women; several taxa more abundant in the transgender cohort have been associated with bacterial vaginosis in other studies.[36] Bacterial vaginosis is separately associated with increased HIV acquisition (RR 1.6, 95% CI 1.2–2.1 in a meta-analysis not specific to transgender patients).[37] Apply chlamydia and gonorrhea screening to transgender men and gender-diverse patients with a cervix using the same age and risk thresholds as for cisgender women; consider pharyngeal and rectal testing by exposure, and counsel on sexual practices according to anatomy and exposure.[6]

Antimicrobial Resistance Concerns​

Antimicrobial resistance remains a concern for gonorrhea, although most strains remain ceftriaxone-sensitive, and for M. genitalium. A meta-analysis found macrolide resistance-associated mutations in 51.4% of successfully characterized M. genitalium samples from 2016–17; 2024 HIVMA/IDSA guidance reports increasing fluoroquinolone resistance.[8][29][30] A 2025 meta-analysis found pooled marker prevalences across collection years of 23.9% for macrolide resistance and 6.5% for fluoroquinolone resistance in specimens from women, with substantial between-study heterogeneity.[46] All gonorrhea treatment failures should have culture with antimicrobial susceptibility testing.[8]

See Also​

References​

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2. US Preventive Services Task Force, Davidson KW, Barry MJ, et al. "Screening for Chlamydia and Gonorrhea: US Preventive Services Task Force Recommendation Statement." JAMA. 2021;326(10):949-956. doi:10.1001/jama.2021.14081

3. Yonke N, Aragón M, Phillips JK. "Chlamydial and Gonococcal Infections: Screening, Diagnosis, and Treatment." Am Fam Physician. 2022;105(4):388-396. PMID 35426632

4. Chevalier FJ, Bacon O, Johnson KA, Cohen SE. "Syphilis: A Review." JAMA. 2025;334(21):1927-1940. doi:10.1001/jama.2025.17362

5. US Preventive Services Task Force, Silverstein M, Wong JB, et al. "Screening for Syphilis Infection During Pregnancy: US Preventive Services Task Force Reaffirmation Recommendation Statement." JAMA. 2025;333(22):2006-2012. doi:10.1001/jama.2025.5009

6. Workowski KA, Bachmann LH, Chan PA, et al. "Sexually Transmitted Infections Treatment Guidelines, 2021." MMWR Recomm Rep. 2021;70(4):1-187. doi:10.15585/mmwr.rr7004a1

7. Klein DA, Valerio CR, Cofield ZN. "Sexually Transmitted Infections: Updated Guideline From the CDC." Am Fam Physician. 2022;105(5):553-557. PMID 35559622

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10. Miller JM, Binnicker MJ, Campbell S, et al. "Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2024 Update by the IDSA and ASM." Clin Infect Dis. 2024. doi:10.1093/cid/ciae104

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18. den Heijer CDJ, Hoebe CJPA, Driessen JHM, et al. "Chlamydia trachomatis and the Risk of Pelvic Inflammatory Disease, Ectopic Pregnancy, and Female Infertility: A Retrospective Cohort Study Among Primary Care Patients." Clin Infect Dis. 2019;69(9):1517-1525. doi:10.1093/cid/ciz429

19. Haggerty CL, Gottlieb SL, Taylor BD, et al. "Risk of Sequelae After Chlamydia trachomatis Genital Infection in Women." J Infect Dis. 2010;201 Suppl 2:S134-155. doi:10.1086/652395

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22. American Cancer Society. Cancer Prevention and Early Detection Facts & Figures. American Cancer Society; 2025.

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27. Bachmann LH, Barbee LA, Chan P, et al. "CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024." MMWR Recomm Rep. 2024;73(2):1-8. doi:10.15585/mmwr.rr7302a1

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30. Machalek DA, Tao Y, Shilling H, et al. "Prevalence of Mutations Associated With Resistance to Macrolides and Fluoroquinolones in Mycoplasma genitalium: A Systematic Review and Meta-Analysis." Lancet Infect Dis. 2020;20(11):1302-1314. doi:10.1016/S1473-3099(20)30154-7

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35. CDC. HPV Vaccine Recommendations. Age and dose schedules.

36. Winston McPherson G, Long T, Salipante SJ, et al. "The Vaginal Microbiome of Transgender Men." Clin Chem. 2019;65(1):199-207. doi:10.1373/clinchem.2018.293654

37. Atashili J, Poole C, Ndumbe PM, Adimora AA, Smith JS. "Bacterial vaginosis and HIV acquisition: a meta-analysis of published studies." AIDS. 2008;22(12):1493-1501. doi:10.1097/QAD.0b013e3283021a37

38. Weström L, Joesoef R, Reynolds G, Hagdu A, Thompson SE. "Pelvic inflammatory disease and fertility. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results." Sex Transm Dis. 1992;19(4):185–192. PMID:1411832. doi:10.1097/00007435-199207000-00001

39. Centers for Disease Control and Prevention. Effects of HIV, Viral Hepatitis and STIs on Pregnancy and Infants. CDC.

40. Serrano B, Alemany L, Tous S, et al. "Potential impact of a nine-valent vaccine in human papillomavirus related cervical disease." Infect Agent Cancer. 2012;7(1):38. doi:10.1186/1750-9378-7-38

41. Centers for Disease Control and Prevention. Pelvic Inflammatory Disease (PID): STI Treatment Guidelines. Updated September 21, 2022. CDC.

42. Centers for Disease Control and Prevention. Clinical Overview of Perinatal Hepatitis B. September 18, 2025. CDC.

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45. AASLD-IDSA HCV Guidance Panel. HCV in Pregnancy. HCV Guidance.

46. Chua TP, Vodstrcil LA, Murray GL, et al. "Evolving patterns of macrolide and fluoroquinolone resistance in Mycoplasma genitalium: an updated systematic review and meta-analysis." Lancet Microbe. 2025;6(7):101047. doi:10.1016/j.lanmic.2024.101047