Universal Chlamydia and Gonorrhea Screening in Young Women

Chlamydia and gonorrhea infection rates are the highest ever reported, and young women 15 to 24 years old are at the highest risk of infection.¹ Because these infections are often asymptomatic,² many otherwise healthy women may not know they are infected. Untreated infections can have severe and long-lasting negative health consequences, including infertility.² Screening for chlamydia and gonorrhea infections in young women is crucial for reducing disease prevalence and facilitating treatment.

Unfortunately, screening rates in young women are low.^1,3 The Centers for Disease Control and Prevention (CDC) has suggested that providers consider universal, or “opt-out,” screening for chlamydia and gonorrhea infections in young women (ie, all young women 15 to 24 years old are tested unless they decline/opt out of testing, regardless of reported sexual activity).²

This article will discuss the importance of universal screening for chlamydia and gonorrhea in sexually active females <25 years old, including the effectiveness of opt-out testing. Also discussed are screening guidelines, barriers to screening, and how healthcare providers can better communicate with patients to encourage appropriate screening.

Young women are at high risk of chlamydia and gonorrhea infection and associated complications

In 2019, reported sexually transmitted infections (STIs) in the United States reached an all-time high for the 6th consecutive year: more than 2.5 million cases of chlamydia, gonorrhea, and syphilis were reported.¹ Chlamydia was the most common STI, with 1.8 million cases reported (an increase of 19% from 2015); almost two-thirds (61%) of the reported cases were in persons 15 to 24 years of age.^1,3,4 Women in this age group accounted for 67% of all female chlamydia cases.^3,5 Gonorrhea was the second-most common STI in 2019; approximately 253,000 cases were reported, an increase from the 241,000 cases reported in 2018.³

Chlamydia and gonorrhea infections in women are commonly asymptomatic and are treated with a course of oral antibiotics.² However, untreated infections can result in pelvic inflammatory disease (PID), chronic pelvic pain, ectopic pregnancy, and infertility; women 15 to 24 years old are at highest risk of these complications.^3,6,7 Every year, undiagnosed STIs are estimated to cause infertility in more than 20,000 women.³

Low screening rates despite guideline recommendations 

Both the CDC and the United States Preventive Services Task Force (USPSTF) recommend that all sexually active women <25 years of age be screened for chlamydia and gonorrhea.^2,8 The CDC recommends screening every year starting at early adolescence.² However, in the absence of sufficient studies to support optimal screening intervals, the USPSTF recommends that screening be based on whether “sexual history reveals new or persistent risk factors since the last negative test result”.⁸

Despite guideline recommendations, only about half of young women identified as sexually active receive chlamydia screening.⁹ The National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) has shown that chlamydia screening rates for women 16 to 24 years of age with commercial HMO or PPO insurance from 2010 to 2020 ranged from approximately 40% to 52%.⁹ Over the same period, screening rates for women with Medicaid HMO coverage ranged from 54% to 58%.⁹

Factors contributing low screening rates

The low screening rates can be attributed to a number of factors.

Barriers to healthcare providers following guideline recommendations for screening may include

• Discomfort discussing sexual health and STIs with patients (see below)^6,10,11
• Gaps in knowledge of screening recommendations¹²
• Awkwardness asking parents for privacy with their minor child (less than half of adolescents report spending time alone with their healthcare provider)¹³

Patient factors contributing to the low screening rates in many young women include⁵

• Lack of understanding about chlamydia and gonorrhea infections (eg, that they can have an infection and not have any symptoms)^2,14,15 (see Sidebar)
• Belief that they are not at risk for infection^2,14,15
• Reluctance to discuss their sexual history with a healthcare provider^2,14,15

Opt-out testing improves screening rates

Opt-out testing for chlamydia/gonorrhea consists of screening all women 15 to 24 years of age as a standard practice, with the patient given the choice to opt out of testing.²

Examples of opt-out testing improving screening rates include

• An increase from 29% to 61% over 18 months among women 16 to 24 years screened for chlamydia (combined with provider and staff education, and resident physician financial incentives [one year after study completion, the screening rate had further increased to 71%])²⁰
• An increase from 23% to 61% over 12 months among adolescents ≥13 years old screened for chlamydia/gonorrhea at a primary care clinic²¹
• An increase from 41% to 50% among 15- to 19-year-old females screened for chlamydia (combined with scheduling examinations and discussion of sexual health topics and electronic health record-based prompts for chlamydia screening)¹⁴

The CDC has stated, “Providers might consider opt-out chlamydia and gonorrhea screening (ie, the patient is notified that testing will be performed unless the patient declines, regardless of reported sexual activity) for adolescent and young adult females during clinical encounters.”² The CDC cited studies suggesting that opt-out chlamydia screening among adolescent and young adult females might substantially increase the screening rate, be cost-saving, and identify infections among patients who do not disclose sexual behavior.² Notably, all 50 states and the District of Columbia explicitly allow minors to consent for their own STI services.²

Beginning the conversation

Many healthcare providers have trouble initiating a conversation about sexual health and STIs. Various organizations provide education and scripts to help initiate conversations, normalize language for discussing STIs, and explain opt-out testing.¹¹

Examples include¹¹

• “We test everyone your age for chlamydia and gonorrhea. These are infections you can get from sexual contact which are common in people your age and usually have no symptoms. Do you have questions or concerns?”
• “I talk to all of my patients about chlamydia screening. Untreated chlamydia can lead to infertility or the inability to have children. The test is simple and all we need is a urine sample.”
• “We ask all of our patients your age if they’ve been tested for chlamydia and gonorrhea recently, since those tests should be done regularly and we don’t want to miss chances to keep you healthy. I’d like to do that today. Do you have questions or concerns?”

As part of mandatory reporting requirements to identify potential abuse, when testing minors under the age of consent, healthcare professionals may be required in certain jurisdictions to report positive results of sexually transmitted disease testing to authorities. 

Patient education

Many patients have limited knowledge about chlamydia and gonorrhea infections.¹⁶ As part of an adolescent healthcare visit, it is important to

• Explain the importance and effectiveness of screening and the potential consequences of untreated infections¹²
• Help patients understand the importance of being honest about their sexual history and addressing confidentiality/privacy concerns¹⁷
• Make time alone with an adolescent to discuss sexual health topics and STI risk a routine part of care^18,19
• Encourage parents and adolescents to have open discussions about sexual health¹⁸

An anonymous survey of parents with at least 1 female or male adolescent 15 to 17 years old found¹³

• Approximately 63% of parents would accept chlamydia and gonorrhea screening for their adolescent if offered by their healthcare provider.
• Parents aware their child was sexually active were significantly more likely to accept screening (81% vs 58%, P<.05).
• Approximately 73% of parents believed it is very important or important that their child spend time alone with the healthcare provider.

How the laboratory can help

Quest Diagnostics offers RNA-based testing for chlamydia and gonorrhea screening, and combined testing for both infections. Quest also has a comprehensive test menu for other STIs, such as human papillomavirus, as well as HIV.

Additional information is available at

• QuestDiagnostics.com/Healthcare-Professionals/Clinical-Education-Center/Conference-Presentations/2020/STI-Testing-Beyond-Chlamydia-Trachomatis---Neisseria-Gonorrhea--
• QuestWomensHealth.com/Well-Woman/Screening-for-STI
• TestDirectory.QuestDiagnostics.com/Test/Test-Guides/CF_Urethritis_Cervicitis_PID/Sexually-Transmitted-Infections-Associated-With-Urethritis-Cervicitis-And-PID?p=r

References

1. Sexually transmitted disease surveillance 2019. Centers for Disease Control and Prevention. Reviewed July 29, 2021. Accessed January 27, 2022. https://www.cdc.gov/nchhstp/newsroom/2021/2019-std-surveillance-report-press-release.html

2. 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

3. Reported STDs in the United States, 2019. Centers for Disease Control and Prevention. Accessed February 3, 2022. https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/std-trends-508.pdf

4. National overview—sexually transmitted disease surveillance, 2019. Centers for Disease Control and Prevention. Reviewed April 13, 2021. Accessed February 10, 2022. https://www.cdc.gov/std/statistics/2019/overview.htm#Chlamydia

5. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2019. Table 10. Chlamydia — reported cases and rates of reported cases by age group and sex, United States, 2015-2019. Reviewed April 13, 2021. Accessed February 11, 2022. https://www.cdc.gov/std/statistics/2019/tables/10.htm

6. Sexually Transmitted Infections National Strategic Plan for the United States: 2021–2025. US Department of Health and Human Services. 2020. Accessed February 3, 2022. https://www.hhs.gov/sites/default/files/STI-National-Strategic-Plan-2021-2025.pdf

7. Pelvic inflammatory disease (PID)—CDC fact sheet. Centers for Disease Control and Prevention. Reviewed July 22, 2021. Accessed January 27, 2022. https://www.cdc.gov/std/pid/stdfact-pid-detailed.htm

8. US Preventive Services Task Force. Screening for chlamydia and gonorrhea: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;326(10):949-956. doi:10.1001/jama.2021.14081

9. Chlamydia screening in women (CHL). NCQA. Accessed January 27, 2022. https://www.ncqa.org/hedis/measures/chlamydia-screening-in-women/

10. Sieving RE, McRee AL, Mehus C, et al. Sexual and reproductive health discussions during preventive visits. Pediatrics. 2021;148(2):e2020049411. doi:10.1542/peds.2020-049411

11. Using normalizing and opt-out language for chlamydia and gonorrhea screening. Family Planning National Training Center. Accessed February 11, 2022. https://rhntc.org/sites/default/files/resources/fpntc_norm_optout_lang_script_2019-04-25.pdf

12. Davis M, Hoskins K, Phan M, et al. Screening adolescents for sensitive health topics in primary care: a scoping review. J Adolesc Health. 2021:S1054-139X(21)00559-0. doi:10.1016/j.jadohealth.2021.10.028

13. Lane K, Miller E, Kisloff L, et al. Many parents would accept sexually transmitted infection screening for their adolescent at a pediatric office visit. J Adolesc Health. 2020;66(5):626-628. doi:10.1016/j.jadohealth.2019.12.019

14. Wood SM, McGeary A, Wilson M, et al. Effectiveness of a quality improvement intervention to improve rates of routine chlamydia trachomatis screening in female adolescents seeking primary preventive care. J Pediatr Adolesc Gynecol. 2019;32(1):32-38. doi:10.1016/j.jpag.2018.10.004

15. Llata E, Cuffe KM, Picchetti V, et al. Demographic, behavioral, and clinical characteristics of persons seeking care at sexually transmitted disease clinics - 14 sites, STD Surveillance Network, United States, 2010-2018. MMWR Surveill Summ. 2021;70(7):1-20. doi:10.15585/mmwr.ss7007a1

16. Hensel DJ, Herbenick D, Beckmeyer JJ, et al. Adolescents' discussion of sexual and reproductive health care topics with providers: findings from a nationally representative probability sample of US adolescents. J Adolesc Health. 2021;68(3):626-628. doi:10.1016/j.jadohealth.2020.06.037

17. Gilbert AL, Rickert VI, Aalsma MC. Clinical conversations about health: the impact of confidentiality in preventive adolescent care. J Adolesc Health. 2014;55(5):672-677. doi:10.1016/j.jadohealth.2014.05.016

18. Society for Adolescent Health and Medicine. Sexual and reproductive health care: a position paper of the Society for Adolescent Health and Medicine. J Adolesc Health. 2014;54(4):491-496. doi:10.1016/j.jadohealth.2014.01.010

19. Sieving RE, Mehus C, Gewirtz O'Brien JR, et al. Correlates of sexual and reproductive health discussions during preventive visits: findings from a national sample of U.S. adolescents. J Adolesc Health. 2021;70(3):421-428.  doi:10.1016/j.jadohealth.2021.10.013

20. Elattma A, Laves E, Taber B, et al. Using provider incentives and an opt-out strategy in a successful quality initiative to increase chlamydia screening. Jt Comm J Qual Patient Saf. 2020;46(6):326-334. doi:10.1016/j.jcjq.2020.03.003

21. Allison BA, Park RV, Walters EM, et al. Increased detection of gonorrhea and chlamydia after implementation of a universal screening protocol in a pediatric primary care clinic. Sex Transm Dis. 2022;49(2):117-122. doi:10.1097/OLQ.0000000000001534

Models used for illustrative purposes.

Published date: Apr 2022