A diabetes mellitus school

This article continues our series looking at the most common sexually transmitted infections. The risk factors, incidence and treatment of genital warts are explained and the care of the patient is described. A case study completes the overview.     

Do not go gently

The authors aimed at conducting an epidemiological analysis of genital chlamydial infection among married couples with infertility problems, women with pelvic inflammatory disease and among patients with promiscuity and clinical symptoms of genital infection in the region of Pleven. They performed a prospective study for a six month period of time. 36 married couples with infertility problems and 66 patients with promiscuity were included in the study. The authors conclude that genital chlamydiosis is a widely spread sexually transmitted disease among a large group of patients. Poor personal hygiene, poor education, young age, some professions which are a predisposition to promiscuity increase the risk of sexually transmitted diseases.     

Association between cytomegalovirus seroconversion and upper genital tract infection among women attending a sexually transmitted disease clinic: a prospective study

To study relationships between acquisition of cytomegalovirus (CMV), sexual activity, and sexually transmitted diseases, 245 CMV-seronegative women were followed (median, 23 months) in a sexually transmitted disease clinic between 1980 and 1988. Thirty-six (15%) seroconverted (10%-12%/year). At entry, seroconverters were younger (P = .03), were younger at sexual debut (P = .004), and had more sex partners (P = .004) than non-seroconverters. During follow-up, seroconverters had more sex partners, had more new sex partners (P = .05 for each), and were more likely to have gonorrhea, chlamydia, or pelvic inflammatory disease. At seroconversion, Chlamydia trachomatis was isolated from cervix in 14%, versus 3% of non-seroconverters (odds ratio [OR], 4.5; 95% confidence interval [CI], 1.3-14.9). Signs of upper genital tract infection were present in 8% of seroconverters versus 2% of non-seroconverters (OR, 4.7; 95% CI, 1.0-21.8). Acquisition of CMV in these women was associated with sexual activity, sexually transmitted diseases, and signs of upper genital tract infection.     

Immunotherapy for non-Hodgkin''s lymphoma

The genital human papillomavirus (HPV) is directly associated with cervical cancer, the second most common form of cancer among women. The study was guided by a synergistic interaction model of HPV risk factors. The relative risk of selected risk factors and cofactors associated with genital HPV infections was identified. Women at highest risk for acquiring an HPV infection had (a) initiated sex before age 15, (b) more than four lifetime sex partners, (c) more than one "once only" sexual partner, and (d) chosen male sex partners who previously had > 16 other female sex partners. Cofactors that increased risk by possibly contributing to progression of genital HPV infection were initiating oral contraceptive use before age 15 and having acquired more than three other sexually transmitted diseases. Past and current smokers were at a slightly higher risk compared to nonsmokers. Although other studies have identified risk factors, few have identified the relative risk of these factors.     

Cytokine and antibody responses in women infected with Neisseria gonorrhoeae: effects of concomitant infections

The levels of interleukin (IL)-1, IL-6, IL-8, IL-10, and transforming growth factor-beta in sera and genital tract secretions from women with gonococcal cervicitis and other genital infections were examined. Cytokines were not elevated in genital secretions from gonococcus-infected compared with uninfected patients. The level of serum IL-6 was higher in gonococcus-infected than in uninfected patients at recruitment. Serum, but not local, IL-1 and IL-6 levels were elevated in patients concomitantly infected with Trichomonas vaginalis or Chlamydia trachomatis in addition to Neisseria gonorrhoeae compared with levels in patients infected with any single organism. Concomitant infection altered neither the total immunoglobulin concentrations nor the levels of antigonococcal antibodies in serum or local secretions. The results suggest that N. gonorrhoeae induces only a limited cytokine and antibody response during uncomplicated cervical infections; however, the presence of other sexually transmitted disease-causing organisms can alter the systemic cytokine but not the antigonococcal antibody levels.     

Factors predicting upper genital tract inflammation among women with lower genital tract infection

We sought to identify factors that discriminate between women with a lower genital tract infection and women with a lower genital tract infection and endometritis. This study enrolled women at risk for or having a lower genital tract infection with Chlamydia trachomatis or Neisseria gonorrhoeae and measured behavioral and clinical factors. Women were identified through contact tracing of male partners, presentation with cervicitis, or presentation with symptoms of pelvic inflammatory disease and classified as (1) having a lower genital tract infection without endometritis, (2) having a lower genital tract infection with endometritis, (3) having no lower genital tract infection with endometritis, and (4) having neither a lower genital tract infection nor endometritis. The primary comparison was between women having a lower genital tract infection without endometritis to women having a lower genital tract infection and endometritis. Women with a lower genital tract infection and endometritis were older and reported a history of more sexually transmitted diseases (70.0% vs. 56.7%), abdominal pain (82.2% vs. 60.0%), and use of barrier methods of contraception (28.9% vs. 8.6%) than women with a lower genital tract infection alone. The regression model found that women with a lower genital tract infection and endometritis were 7.1 times (95% CI = 2.2-23.0) more likely to report abdominal pain and 4.6 times (95% CI = 1.5-14.9) more likely to use barrier methods of contraception than women with a lower genital tract infection alone. These results suggest that behavioral factors, in addition to symptoms, can be used to identify women with and without upper genital tract involvement.     

The sensitivity of a syndromic management approach in detecting sexually transmitted diseases in patients at a public health clinic in Cape Town

OBJECTIVES: To evaluate the sensitivity of a syndromic diagnostic procedure in detecting and treating sexually transmitted diseases (STDs) and genital tract infections (GTIs). METHODS: All new patients presenting at an STD clinic were sampled systematically by gender over a 6-week period. After the patient's clinical consultation, the clinical records were reviewed. Thereafter all patients were given a thorough genital examination by the research physician, and specimens were collected for laboratory investigations. In a retrospective simulation clinicians' syndromic diagnoses were validated against the laboratory findings, or for genital ulcer syndrome against the findings of the research physician. RESULTS: 170 men and 161 women were included in the sample. Ninety-five per cent of patients were black and the median age was 22 years for women and 26 years for men. In this setting, the Western Cape syndromic diagnostic procedure achieved reasonable levels of sensitivity in detecting Neisseria gonorrhoeae and Chlamydia trachomatis in men and women, and in detecting Trichomonas vaginalis and bacterial vaginosis in women. However, it was estimated to be only 36.4% sensitive in detecting genital ulcers in women, and between 0% and 12.3% sensitive in detecting Candida albicans. With syndromic management 8.2% of men and 32.9% of women would leave the clinic with at least one infection inadequately treated. CONCLUSIONS: Despite the introduction of syndromic protocols, it is likely that a proportion of STDs and GTIs are not being detected and treated owing to the high prevalence of multiple syndromes and mixed infections, both symptomatic and asymptomatic.     

Preventing pelvic infection after abortion

Pelvic infection is the commonest complication of legal abortion. The presence of lower genital tract infections increases the risk of complications, and women requesting abortion are at significant risk of harbouring sexually transmitted diseases (STD). Prophylactic antibiotic treatment can decrease the rate of post-abortal sepsis, but the optimum regime is unclear. In particular, patients with Chlamydia trachomatis infection, and bacterial vaginosis would appear to be at increased risk, and detection and treatment of these conditions can lower this risk. The opportunity to screen and treat for STD presents itself in this setting, allowing patients and their sexual contacts to benefit, with a decrease in the infected pool in the community.     

Some neurophysiologic aspects of consciousness

This article presents the results of an assessment of gynecological morbidity among 385 women with young children residing in a district of Karnataka State, South India. All three main modes of assessment (clinical examination, laboratory tests, and self-reports) reveal a high burden of reproductive tract infections. The two most common conditions, identified by laboratory tests, were bacterial vaginosis and mucopurulent cervicitis. Approximately one-fourth of the women had clinical evidence of pelvic inflammatory disease, cervical ectopy, and fistula. The contribution of sexually transmitted diseases to overall gynecological morbidity appears to be relatively modest; 10 percent were so diagnosed. Associated conditions of anemia and chronic energy deficiency were common. Severe anemia was found in 17 percent of cases and severe chronic energy deficiency in 12 percent. These results indicate that radical improvements in women's health in India will require far more than the diagnosis and treatment of reproductive tract infections.     

Sexual risk behaviour in women carriers of Mycoplasma hominis

OBJECTIVE: To study the sexual behaviour of women harbouring Mycoplasma hominis in the vagina. SETTING: Two family planning clinics and a youth clinic for contraceptive advice. METHODS: The vaginal flora of 996 women were investigated microbiologically, including culturing for M. hominis from the posterior vaginal fornix. Cultures and tests were also made to diagnose genital Chlamydia trachomatis infections, gonorrhoea, genital herpes, cervical human papillomavirus infection, trichomoniasis, genital warts and human immunodeficiency virus. The sexual behaviour of these women was investigated by structured in-depth personal interviews. RESULTS: Of the 996 women, 123 (12.3%) harboured M. hominis in the vagina. The remainder (87.7%), who had a negative M. hominis culture, served as a reference group. Those with M. hominis were significantly more likely to have had more than 10 partners during their lifetime, had a greater frequency of more than one sexual partner during the preceding month and the last six months, and reported more frequent experience of "casual sex', including casual "travel sex'. More of them also had experience of group sex and were more likely to have been sexually abused than the women in the reference group. Fewer women with M. hominis had a current steady partner and were less often cohabitors, but more had had sexual intercourse during the previous week than those in the reference group. There was an association between the occurrence of M. hominis and bacterial vaginosis and genital chlamydial infection. Adjustment in multifactorial regression analyses therefore changed the results only marginally. CONCLUSIONS: Women with M. hominis have almost the same sexual risk behaviour as women with classic sexually transmitted diseases.     

New cases seen at genitourinary medicine clinics: England 1997

Statistics from genitourinary medicine (GUM) clinics provide the most comprehensive source of data on the epidemiology of sexually transmitted infections (STI) in England. Between 1996 and 1997, the total number of diagnoses made in GUM clinics rose by 7% and total diagnoses of acute STIs by 9%. Diagnoses of genital Chlamydia trachomatis, genital warts and gonorrhoea rose by 20%, 8%, and 5%, respectively. Cases of infectious syphilis rose by 26%, most of which was attributable to an outbreak in Bristol. These rises followed substantial rises in acute STIs between 1995 and 1996, and were most pronounced among teenagers and homosexual and bisexual men. The continued growth in numbers of acute STIs is occurring despite the targeting of known risk groups in sexual health education and intervention programmes, and suggests that renewed efforts to improve sexual health are needed.     

A three-dimensional photographic method for documentation and measurement of dental conditions

GOALS: To describe the interrelationships of douching, sex during menses, dry sex, and anal intercourse and their associations with self-reported history of sexually transmitted diseases (STD). STUDY DESIGN: The authors interviewed by telephone 422 white Americans (WA) and 44 African Americans (AA) selected using random-digit dialing, and 135 AA selected from a listed sample of census tracks having a population of at least 40% AA. RESULTS: After adjusting for lifetime numbers of vaginal sex partners, sex during menses was associated with self-reported history of chlamydial infection among women (WA: odds ratio [OR] = 3.9; confidence interval [CI]: 1.1, 14.0; AA: OR = 1.6; CI: 0.6, 4.2). Anal sex was associated with self-reported history of genital warts, genital herpes, hepatitis, and gonorrhea; douching with a twofold increase in self-reported pelvic inflammatory disease. Anal sex was most common in women with a history of same- and opposite-sex partners. CONCLUSIONS: These data confirm the association of douching and anal sex with various STD and suggest that sex during menses is associated with chlamydial infection.     

Community based study of treatment seeking among subjects with symptoms of sexually transmitted disease in rural Uganda

This paper presents a community based study of treatment seeking among people with symptoms of sexually transmitted diseases (STDs) in rural Uganda. The effects of asymptomatic infections and treatment seeking behavior on control of sexually transmitted disease were quantified. The study suggests that treating only individuals with STD symptoms results in only a small proportion of the infected population being reached. This situation leads to fewer people receiving effective health care. Thus, STD control programs in medically underserved populations must take into account the prevalence of asymptomatic infections and the health related practices of people with STDs symptoms to design strategies for reducing transmission of these diseases.     

Sexually transmitted infections among sex workers in KwaZulu-Natal, South Africa

OBJECTIVE: The purpose of this study was to investigate the prevalence of sexually transmitted infections, including human immunodeficiency virus (HIV), among female sex workers operating at truckstops in the KwaZulu-Natal midlands of South Africa. METHODS: A total of 145 sex workers were recruited from August 1996 to March 1997. A gynecologic examination, including a speculum examination, was performed. Investigations were performed to identify gonorrhea, syphilis, chlamydia (infection), candidiasis, trichomoniasis, bacterial vaginosis, and HIV infection. RESULTS: A total of 50.3% of the sex workers were HIV positive. Infection with Trichomonas vaginalis was present in 41.3% of the women, Candida albicans in 40.6%, Neisseria gonorrheae in 14.3%, and Chlamydia trachomatis in 16.4%. Bacterial vaginosis was present in 71% and active syphilis in 42.1% of the women. CONCLUSION: The high prevalence of sexually transmitted infections, including HIV, clearly highlights the urgent need for interventions. In addition to empowering women with methods they can use and control to reduce their risk of infection, an effective approach to control of sexually transmitted infections also needs to recognize the role of the clients, such as truck drivers, so that they also are targeted for interventions.     

Sexually transmitted disease acquisition among women infected with human immunodeficiency virus type 1

Recent evidence suggests that sexually transmitted diseases (STDs) enhance the transmission of human immunodeficiency virus (HIV) type 1. In 143 HIV-infected women enrolled in a university-based longitudinal HIV clinic over 16 months (mean), the STD point prevalence was examined at enrollment and the cumulative prevalence was calculated at follow-up. At enrollment, 35 women (25%) had > or = 1 STD. These included trichomoniasis in 16 women (11%); syphilis, 9 (6%); genital herpes, 8 (6%); gonorrhea, 5 (4%); chlamydia, 5 (4%); genital warts, 2 (1%); and pelvic inflammatory disease (PID), 1 (1%). STDs were found in 55 (42%) of the 125 patients who returned for at least one follow-up visit: trichomoniasis in 23 (18%); genital herpes, 20 (12%); gonorrhea, 9 (7%); syphilis, 7 (6%); genital warts, 7 (6%); chlamydia, 5 (4%); and PID, 4 (3%). Despite counseling at both enrollment and follow-up, these women had a very high cumulative prevalence of STDs, indicating persistent high-risk sexual behavior.     

Contraception and the prevention of sexually transmitted diseases

Sexually transmitted diseases (STDs) are a major cause of ill health in women and their sexual partners and children. Contraceptive methods alter in various ways the risk of acquiring STD but assessment of the odds ratio is difficult due to the many confounding factors. Spermicides have been reported to kill a wide range of bacteria and viruses including HIV in vitro and to protect in vivo from infection by gonorrhoea, chlamydia and pelvic inflammatory disease (organisms unspecified). Spermicides will not cure pre-existing infections. Condoms and diaphragms will give some protection from bacterial and viral infections in all parts of the genital tract. Hormonal contraception and tubal ligation give protection to the upper genital tract but not the cervix. Carcinoma of the cervix follows the same pattern as STDs. The risk of pelvic infection in intrauterine device users is discussed in the chapter by Bromham (pp 100-123, this issue).     

A controlled trial of nonoxynol 9 film to reduce male-to-female transmission of sexually transmitted diseases

BACKGROUND: Nonoxynol 9 is a proved spermicide, but whether it is also a microbicide is uncertain. A truly effective vaginal microbicide would reduce the susceptibility of women to sexually transmitted diseases, including infection with the human immunodeficiency virus (HIV). METHODS: We enrolled 1292 HIV-negative female sex workers in Cameroon and enrolled them in a double-blind, placebo-controlled study in which the participants were randomly assigned to use either a film containing 70 mg of nonoxynol 9 or a placebo film, inserted into the vagina before intercourse. All of the women were provided with latex condoms and were instructed to have their male sexual partners use them. At monthly follow-up visits, we examined the women with a colposcope for genital lesions, tested endocervical specimens for gonorrhea and chlamydia infection with DNA probes, tested for HIV infection, and treated the women for curable sexually transmitted diseases. RESULTS: The rates of HIV infection (cases per 100 woman-years) were 6.7 in the nonoxynol 9 group and 6.6 in the placebo group (rate ratio, 1.0; 95 percent confidence interval, 0.7 to 1.5). The rates of genital lesions were 42.2 cases per 100 woman-years in the nonoxynol 9 group and 33.5 in the placebo group (rate ratio, 1.3; 95 percent confidence interval, 1.0 to 1.6). The rates of gonorrhea were 33.3 and 31.1 cases per 100 woman-years in the nonoxynol 9 and placebo groups, respectively (rate ratio, 1.1; 95 percent confidence interval, 0.8 to 1.4). The corresponding rates of chlamydia infection in the nonoxynol 9 group and the placebo group were 20.6 and 22.2 per 100 woman-years (rate ratio, 0.9; 95 percent confidence interval, 0.7 to 1.3). The women reported that condoms were used during 90 percent of sexual acts. CONCLUSIONS: The use of a nonoxynol 9 vaginal film did not reduce the rate of new HIV, gonorrhea, or chlamydia infection in this group of sex workers who used condoms and received treatment for sexually transmitted diseases.     

Factors associated with appropriate physician management of sexually transmitted diseases in an urban Canadian center

BACKGROUND AND OBJECTIVES: To explore physicians' management of selected sexually transmitted diseases (STDs), because previous studies suggest that physicians' management practices could be improved. GOALS: To determine the estimated annual incidence of STD seen by family/general practitioners (FPs), gynecologists (GYNs) and urologists (UROLs), adequacy of STD management practices, and any associations with demographic and other characteristics. STUDY DESIGN: A self-administered questionnaire was mailed to GYNs, UROLs, and a random sample of FPs in Hamilton, Ontario. RESULTS: Eighty-one of 102 (79.4%) FPs, 27 of 32 (84.4%) GYNs, and 7 of 8 (87.5%) UROLs responded. Vaginitis, male urethritis, and genital warts in women were the most frequently observed STDs. The treatment of bacterial vaginosis and pelvic inflammatory disease were most frequently at variance with published guidelines. CONCLUSIONS: Deficiencies exist in physicians' management of both common and potentially serious STD problems.     

Possible non-sexual transmission of genital human papillomavirus infections in young women

Human papillomaviruses were detected by an in vitro enzymatic DNA amplification method in cells obtained from vulvar swabs of 9 of 61 (14.8%) young women without prior experience of sexual intercourse and in 7 of 57 (12.3%) young women with prior experience. The prevalence of human papillomavirus DNA in these two groups of women was not significantly different (x2 = 0.16, p > 0.5; 95% confidence interval -0.165 to 0.215). These results suggest that genital human papillomavirus is not sexually transmitted in all cases and that it may be acquired by modes other than sexual contact.     

Genomic variation of human papillomavirus type 16 and risk for high grade cervical intraepithelial neoplasia

BACKGROUND: Epidemiologic studies have demonstrated strong and consistent associations between the detection of human papillomavirus (HPV) type 16 DNA and the risk of cervical intraepithelial neoplasia (CIN) and cervical cancer. However, HPV16 is also the most common type of HPV in the normal population, and only a minority of women with HPV16 infection develop cervical cancer. Studies of genomic heterogeneity in HPV16 have demonstrated the presence of multiple variant forms in all human populations examined to date. It is conceivable that the natural variants of HPV16 in a given population may not have the same biologic behavior. PURPOSE: This study was designed to determine the association between natural variants of HPV16 and the risk of biopsy-confirmed CIN 2 or 3, the most important precancerous lesions of the uterine cervix. METHODS: Prospective studies were conducted among 1) women attending a university and 2) women presenting to a sexually transmitted disease clinic. Subjects were eligible for inclusion in this investigation if the initial cytologic findings did not reveal CIN 2-3 and HPV16 DNA was detected by means of a polymerase chain reaction (PCR)-based method in one or more cervical or vulvovaginal samples. Eligible subjects were followed every 4 months with cervical Pap smears and colposcopic examinations. Women were referred for biopsy if cytology or colposcopy suggested CIN 2-3. Two groups of HPV16 variants, prototype-like and nonprototype-like, were determined by means of single-strand conformation polymorphism (SSCP) analysis of PCR products from the noncoding region of the viral genome. Representative SSCP patterns from HPV16 variants were further characterized by direct DNA sequencing of the PCR products. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated by Cox regression analysis. RESULTS: Prototype-like variants accounted for 79% of the HPV16 detected in university students and 86% of the virus detected in patients presenting to the sexually transmitted disease clinic. CIN 2-3 was confirmed by biopsy in nine of 57 HPV16-positive women attending the university and in 10 of 66 HPV16-positive women presenting to the sexually transmitted disease clinic. Among university students, those with HPV16 nonprototype-like variants were 6.5 (95% CI = 1.6-27.2) times more likely to develop CIN 2-3 than those with prototype-like variants. A similar association was observed among women presenting to the sexually transmitted disease clinic (RR = 4.5; 95% CI = 0.9-23.8). CONCLUSIONS: This study suggests that the risk of developing CIN 2-3 is not the same with all variants of HPV16 and that nonprototype-like variants confer a greater risk compared with prototype-like variants. The important genomic differences underlying this increased risk of CIN 2-3 remain to be determined.