[Question #295] Mycoplasma Genitalium

108 months ago

Hello,

After engaging with a new partner, he started to complain of abnormal discharge. Around the same time, I experienced abnormal discharge and pelvic pain. We both were tested for gonorrhea and chlamydia and were given a 1G dose of Azithromycin as a possible contact. Both tests came back negative, but symptoms persisted. After several visits with physicians and a urologist and treatment failures with Doxycycline and Cipro, he was treated for suspected mycoplasma genitalium with a 400-mg, 5-day course of Moxifloxacin. His symptoms resolved after this.

I have bounced back and forth with a Planned Parenthood clinic and a couple public health clinics, as I don’t have insurance. I have shown symptoms and biological markers of bacterial vaginosis and have been prescribed a 10-day dosage of Metronidazole, 5-day course of Metronidazole gel and a single-dose Diflucan. My symptoms had worsened and include abnormal discharge, pelvic pain, pain during sex and spotty bleeding. After my partner’s treatment success, I convinced the public health clinic to prescribe the same treatment. I was re-tested for gonorrhea, chlamydia and trichomoniasis. The tests came back negative, and I was prescribed a 10-day course of 400-mg Moxifloxacin. Around day 6, my pelvic pain and discomfort seemed to worsen. After finishing the Moxifloxacin, the pain persists. Between treatments of Metronidazole, I was also diagnosed with strep throat and treated with 10 days of Amoxicillin (just to give a picture of my antibiotic use).

I haven’t encountered any practitioners that are terribly familiar with mycoplasma genitalium. I have read several studies that Moxifloxacin is the last line of treatment for failures with Azithromycin and Doxycycline and appears to be the most effective. I am uncertain at this point where to go and who to reach out to. I pay out-of-pocket and am willing to make an investment with someone who understands my problem, but also don’t want to waste money hopping around. I live in the Denver area. Any advice or contact information would be much appreciated.

Thank you.

H. Hunter Handsfield, MD

108 months ago

Welcome to the forum and thanks for your question.

I'm afraid my answers won't be entirely satisfying. The issues you face are at the cutting edge of the newest bacterial STD -- more accurately, new knowledge about it. That is, understanding of Mycoplasma genitalium and its effects and best treatment are still evolving, with many unanswered questions. Among the issues that has been very little studied so far is M gen's role in pelvic inflammatory disease (PID) and the sorts of symptoms you describe. It's not at all surprising that you haven't found any doctors who seem especially knowledgeable about it.

However, one thing we do know from our understanding of cervicitis, PID, and symptoms like yours is that regardless of the initiating infection, other bacteria -- typically the same ones involved in bacterial vaginosis -- often contribute to inflammation and symptoms. That is, chlamydial or gonococcal PID needs treatment for more than just chlamydia and gonorrhea. Almost certainly the same is true for M. genitalium. In other words, regardless of M gen's possible initial role in your symptoms, treating M gen alone may not be sufficient.

That said, you have taken a wide range of antibiotics which, together or in combination, usually are effective against PID, regardless of the initial cause. Although the combination of moxifloxacin, amoxicillin, and metronidazole is not a one of the regimens specifically recommended against PID, usually it would work well. Even with the most effective PID treatments, pain often persists. Therefore, I cannot suggest any additional treatment likely to be helpful at this time. At this point, the main question is whether there is still any active infection, or just leftover scarring, in which case more antibiotics won't help. Answering this probably will require more sophisticated gynecologic care than you have had so far. Denver Public Health's STD clinic is one of the premier STD centers in the US; and while I can't speak to Denver's PP clinics, my guess is they also provide high quality care. At the same time, you may need more extensive diagnostic evaluation than they would normally undertake, such as pelvic ultrasound or CT scan, laparoscopy, etc.

So my specific advice to re-contact the STD clinic; explain the problem (perhaps by phone, but maybe best in person); and ask their advice about referral to a sophisticated gynecologist who understands these sorts of things. Denver Public Health has a very close working relationship with University of Colorado gynecology, which in turn includes nationally recognized experts in gyn infections, STDs, etc. DPH also should be able to directly address your insurance issue and options for ongoing care, including assessment and perhaps getting you signed up for coverage under the Affordable Care Act. (You certainly could also go through PP or your personal physician, but DPH would be my first choice personally.)

I hope these comments have been helpful. Best wishes for a successful outcome-- HHH, MD

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H. Hunter Handsfield, MD

108 months ago

I should add that the one STD not reliably treated by one or more of the antibiotics you received is gonorrhea. But i assume you and your partner were tested for it, perhaps more than once; and although some gonorrhea is resistant to one or more of these drugs, most cases would in fact respond. But something to keep in mind as a slim possibility when you speak with your doctor(s).

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