Sexually transmitted diseases among teenagers in England and Wales

A profile of sexually transmitted diseases (STDs) and HIV infections among teenagers in England and Wales was obtained from reports of newly diagnosed STDs among teenagers attending genitourinary medicine (GUM) clinics in 1995, laboratory reports of newly diagnosed HIV infections between 1985 when reporting began and the end of 1995, and the prevalence of HIV (unlinked anonymous programme) among teenagers attending genitourinary medicine clinics and antenatal clinics in 1994 and 1995. STD reports were analysed by sex, age group, and place of residence of patients--whether in the NHS Thames regions or elsewhere in England and Wales. High rates of STDs were reported in teenagers, particularly in girls. The incidences of gonorrhoea, chlamydia infection, and first attack genital wart infections were higher in teenage girls than in any other age group. Boys under 16 years of age had substantially higher rates of infection with all STDs in the Thames regions than elsewhere. Rates of gonorrhoea in teenagers of both sexes in the Thames regions were more than twice those in the rest of the country. Infection rates for genital herpes, and chlamydia in girls, were also higher in the Thames regions, although the geographical differences were less marked. The seroprevalence of HIV among heterosexual teenagers was very low. In contrast, 226 HIV infections among teenage boys had probably been acquired through sexual intercourse with other males. Unlinked anonymous testing revealed HIV antibody in 7.5% of routinely collected serology specimens taken from teenage homosexual or bisexual males attending GUM clinics in London. The high rates of STDs among teenage girls and all teenagers in the Thames regions make these groups a high priority for sexual health promotion, with special consideration given to homo/bisexual male teenagers. Detailed surveillance of risk factors for STDs, and further studies of teenage sexual behaviour will help to effectively target resources to improve the sexual health of teenagers in England and Wales.     

Involvement of the pelvic plexus and the suprarenal ganglia in the neuropeptide Y (NPY) innervation of the cervix and the uterus of the rat

The involvement of the pelvic plexus and suprarenal ganglia in the neuropeptide Y (NPY) innervation of the genital tract was studied in the female rat by means of denervation experiments and retrograde tracing studies. Removal of the paracervical ganglia caused a significant decrease of the NPY-immunoreactive nerve density and NPY concentration in the lower part of the genital tract: cervix, uterine body and lower part of the uterine horn. The decrease in NPY concentration in these three regions was more pronounced after lesion of the pelvic plexus. Lesion of the ovarian nerve plexus caused a depletion in the NPY-immunoreactive nerve fibres and a decrease in NPY concentration in the upper part of the uterine horn. Pelvic nerve section, inferior mesenteric ganglia excision and superior ovarian nerve section had no effect on the NPY innervation in the genital tract. Injection of fluorogold into the cervix and lower part of the uterus combined with immunohistochemistry revealed that 87.5% of labelled neurons in the pelvic plexus were NPY-immunoreactive. Following injection of fluorogold into the upper part of the uterus, 92% of labelled neurons in the suprarenal ganglia were NPY-immunoreactive. Treatment with 6-hydroxydopamine revealed that the NPY-immunoreactive nerve fibres were non-noradrenergic in the cervix, but were noradrenergic in the upper part of the uterus. In the uterine body and lower part of the uterine horn, both noradrenergic and non-noradrenergic NPY-immunoreactive nerve fibres were observed. These data demonstrate the major contribution of pelvic plexus neurons in the non-noradrenergic NPY innervation of the lower part of the genital tract, and the involvement of the suprarenal ganglia in the noradrenergic NPY innervation of the upper part of the uterus via the ovarian nerve plexus.     

Incidence of herpes virus (HSV-2) alterations in squamous cells of vagina epithelium (author's transl)

The authors have analysed 17,519 cytological cervix smears. Alterations characteristic of HSV infection were recorded from squamous cells of vaginal and cervical epithelia in 21 cases (0.12 per cent). Incidences of cytologically detected HSV infection of the vagina and cervix were 0.17 per cent among female factory workers and 0.08 per cent among peasant women. No statistically unambiguous difference was found to exist between the incidences of genital HSV infections in the two groups examined (p greater than 0.05). The majority of women with genital HSV infections was between 21 and 25 years old.     

Risk factors for plasma cell endometritis among women with cervical Neisseria gonorrhoeae, cervical Chlamydia trachomatis, or bacterial vaginosis

OBJECTIVE: We sought to determine potential risk factors for upper genital tract inflammation in women with cervical Neisseria gonorrhoeae, Chlamydia trachomatis, or bacterial vaginosis. STUDY DESIGN: In a case-controlled study we compared 111 women with cervical Neisseria gonorrhoeae, Chlamydia trachomatis, or bacterial vaginosis (the study group) with 24 women who had negative tests for each of these infections (the control group). We evaluated potential risk factors for upper genital tract inflammation by use of bivariate and then logistic regression analysis. RESULTS: We found plasma cell endometritis in 53 of 111 women in the study group and 3 of 24 controls (odds ratio = 6.4, 95% confidence interval 1.7 to 35.0). On logistic regression, the study group women who were in the proliferative phase had increased likelihood of plasma cell endometritis (odds ratio = 4.5, 95% confidence interval 1.6 to 12.4). CONCLUSION: The proliferative phase of the menstrual cycle seems to be the primary risk factor for ascending infection by organisms associated with pelvic inflammatory disease. This may be due to a hormonal effect or to the loss of the cervical barrier during menstruation.     

Chlamydial genital infections and laparoscopic findings in infertile women

Several studies have shown that previous chlamydial genital infection, reflected by serological markers, is strongly associated with tubal damage leading to tubal infertility. In 105 women undergoing laparoscopy, multiple samples were collected from the lower (urethra and cervix) and upper (endometrium, peritoneal fluid, tubal lumen) genital tract, in order to isolate Chlamydia trachomatis in cell culture. Chlamydia trachomatis was isolated from at least one site in 13 (30.9%) of 42 infertile women with tubal infertility, in 5 (12.1%) of 41 women with unexplained infertility, in 1 of 4 women affected by acute salpingitis and in 1 (5.5%) of 18 women with endometriosis or uterine malformations. The latter group was the control group. Thirteen (65%) of the 20 positive women harboured Chlamydia trachomatis in their upper genital tract alone and 16 women were positive in one or both tubes. Only one of the positive women showed laparoscopic signs of acute pelvic infection. Four of the 5 positive women with unexplained infertility harboured Chlamydia trachomatis in the tubal lumen. This study confirms that chlamydial infection is strongly associated with tubal damage. It suggests that cervical cultures are inadequate for excluding a tubal infection and that chlamydial colonization of the tubal mucosa is possible in the absence of symptoms and laparoscopic signs of active infection.     

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.     

High prevalence of sexually transmitted diseases in women with urinary infections

OBJECTIVE: To determine the prevalence and factors associated with unrecognized sexually transmitted diseases (STDs) in women who had pelvic examinations and were subsequently released from the ED with a sole diagnosis of urinary tract infection (UTI). METHODS: A 3-month retrospective chart review was performed in an urban teaching hospital ED (> 70,000 visits/year). Women aged 12-45 years who had pelvic examinations and were released from the ED with a sole diagnosis of UTI were included. Patient complaints, physical findings, and laboratory results were reviewed. Laboratory evaluations included the complete blood count, urinalysis, urine pregnancy test, and cervical cultures for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas. RESULTS: Of the 94 women who met study criteria, 53% had proven STDs (19% N. gonorrhoeae, 22% C. trachomatis, 33% Trichomonas). There was no difference between the patients with positive and negative tests for STDs with regard to complaints, physical findings, and laboratory results (all p > 0.05). CONCLUSIONS: Women undergoing pelvic examinations who are subsequently released from this urban ED with the diagnosis of UTI have a high (> 50%) prevalence of occult STDs. No complaint, physical finding, or laboratory result reviewed was associated with the risk of an STD. Consideration should be given to empirical antibiotic therapy in similar urban populations.     

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.     

Chlamydia trachomatis infections

Chlamydia trachomatis is the most common bacterial cause of sexually transmitted disease in the developed countries. The most important implications of genital chlamydia infections involve the reproductive health sequalae of upper genital tract infections in women: pelvic inflammatory disease, ectopic pregnancy, and infertility, infection by this organism is insidious, symptoms are absent or minor among most infected women and many man. This large group of asymptomatic and infectious persons sustains transmission within a community. This review discusses the epidemiology, of sexually transmitted chlamydial infections, the spectrum of clinical manifestations and their sequelae, the laboratory diagnosis of genital chlamydiasis, antibiotic treatment and prevention.     

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.     

Studies in knockout mice reveal that anti-chlamydial protection requires TH1 cells producing IFN-gamma: is this true for humans?

Chlamydia trachomatis is one of the major causes of infertility and preventable blindness in the world. The organism is of particular interest from an immunological point of view because it is one of the few obligate intracellular bacterial pathogens. There is some evidence that repeated infections in humans stimulate protective immunity. However, until recently, it was unclear which components of the adaptive immune system give rise to protection. Studies in gene knockout mice reported here and elsewhere now give a coherent and cogent picture of the importance of the Th1 response, in particular IFN-gamma, for the localization and eradication of C. trachomatis genital tract infection. The key questions still to be addressed are the identity of the IFN-gamma responsive cells and whether the mouse is truly representative of host protection against chlamydiae in humans.     

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.     

Family planning services in developing countries: an opportunity to treat asymptomatic and unrecognised genital tract infections?

OBJECTIVE: To determine the prevalence of asymptomatic and unrecognised genital tract infections among women attending a family planning clinic in rural South Africa. METHODS: 189 consecutive women had genital samples taken to diagnose infection with Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Candida albicans, Treponema pallidum, and HIV, and to diagnose bacterial vaginosis. RESULTS: Mean age was 25 years; 155 (82%) were unmarried, 156 (83%) were currently using contraception, and 41 (22%) reported having an STD treated in the preceding 12 months. Although none volunteered abnormal urogenital symptoms, 74 (39%) had at least one elicited by direct questioning. 119 women (63%) had at least one genital infection: N gonorrhoeae (eight; 4%), C trachomatis (14; 8%), T vaginalis (26; 14%), C albicans (56; 30%), active syphilis (15; 8%), HIV (44; 24%), and bacterial vaginosis (29; 15%). 49 women (26%) had multiple infections. Most infections (71; 60%) were asymptomatic. Symptomatic women failed to recognise and report their symptoms, and routine services failed to detect the infections. CONCLUSION: Prevalence of genital tract infection is high among these women, most infections are asymptomatic, and symptomatic infections are frequently not recognised. Women attending family planning clinics in such settings should be screened for syphilis and offered testing for HIV infection. Strategies to detect and treat other genital infections need to be developed.     

Displacement of the tubular genital tract of the ewe during pregnancy

The displacement of the tubular genital tract of ewes during pregnancy, in particular of the cervix relative to the cranial pelvic brim, was studied by sequential radiography using radio-opaque markers attached surgically before tupping. In the first year, 13 two-year-old parous ewes were fed a complete pelleted diet containing either 15 or 25 per cent fibre throughout pregnancy. The distances between the markers attached to the tubulogenital tract increased and the distance between the cervix and the cranial pelvic brim increased slightly with advancing pregnancy; the diet had no effect. In the second year, only cervical displacement was studied in 11 ewes that had suffered a cervicovaginal prolapse the previous year, and in five of their female progeny. They were divided into two groups, one of which was fed a 15 per cent-fibre complete pelleted diet and the other hay ad libitum throughout pregnancy. In two ewes, one from each dietary group, the prolapse recurred less than two weeks from term; initially it was a stage 2 prolapse, where the vaginal wall fails to return to its normal position when the ewe stands, but in one ewe it became a stage 3 prolapse, with the vagina completely everted and the cervix visible. During the stage 2 prolapse there was no evidence of caudal displacement of the cervix, whereas during the progression to the stage 3 prolapse the cervix became displaced 33 cm caudally over two to three hours.     

Spread of HIV infection in married monogamous women in India

CONTEXT: A high prevalence of human immunodeficiency virus (HIV) infection in female sex workers (FSWs) and men who attend sexually transmitted disease (STD) clinics poses a risk for spread of infection to other populations. OBJECTIVE: To examine spread of HIV to a low-risk population by comparing prevalence of, and risk factors for, HIV and STDs in FSWs and non-FSWs. METHODS: Women attending STD clinics in Pune, India, were assessed for STDs and HIV from May 13, 1993, to July 11, 1996. Demographic and behavioral information was collected, and clinical and laboratory assessment was performed. MAIN OUTCOME MEASURE: Prevalence and risk determinants of HIV infection. RESULTS: Of 916 women enrolled, 525 were FSWs and 391 were non-FSWs. Prevalence of HIV in FSWs and non-FSWs was 49.9% and 13.6%, respectively (P<.001). In multivariate analysis, inconsistent condom use and genital ulcer disease or genital warts were associated with prevalent HIV in FSWs. History of sexual contact with a partner with an STD was associated with HIV in non-FSWs. CONCLUSIONS: Infection with HIV is increasing in non-FSWs, previously thought to be at low risk in India. Since history of sexual contact with their only sex partner was the only risk factor significantly associated with HIV infection, it is likely that these women are being infected by their spouses. This underscores the need for strengthening partner-notification strategies and counseling facilities in India.     

Perceptions and patterns of reproductive tract infections in a young rural population in North-West Namibia

Syndromic management of sexually transmitted diseases (STDs) is strongly promoted in Namibia. However, no data are available on rates of asymptomatic reproductive tract infections (RTIs) which would remain undetected and thus untreated in the general population. This study was aimed at assessing the prevalence of RTIs in a young rural population and to gain an insight into their health-care seeking behaviour for RTIs. A total of 97 patients (44 male, 53 female) <30 years of age attending the outpatient clinic of a rural hospital in Northern Namibia for problems unrelated to RTIs were interviewed and examined. Specimens were taken for investigation of RTIs according to a non-invasive diagnostic schedule. Laboratory examinations revealed 58 infections of the reproductive tract in 42 of the 97 patients (43%). In addition, HIV infection was detected in 13 cases (13%). RTI rates were highest in female teenagers (68%), but no infections were detected in their male counterparts. Of those 42 patients with a laboratory-diagnosed infection, 7 had both symptoms and signs (symptomatic), 16 had neither symptoms nor signs (asymptomatic), and 19 had signs on examination but no symptoms (inapparent). Awareness and perception of symptoms and signs of RTIs were low in the studied population. Provision of adequate treatment for RTIs alone is unlikely to have a major impact on the overall burden of disease since the largest burden of disease was found among those patients (predominantly females) with inapparent infections. Health education on RTIs including STDs and the symptoms they cause together with the importance of early attendance at health facilities and improved access to treatment need to be addressed urgently.     

An association exists between bovine herpesvirus-4 seropositivity and abortion in cows

The prevalence of cattle seropositive to bovine herpesvirus-4 (BHV-4) is high in Belgium. In Belgian farms, clinical signs associated with BHV-4 infection essentially involve the genital tract and consist mainly of postpartum metritis or metroperitonitis. The role of BHV-4 in abortion has not been definitively demonstrated but epidemiological and experimental facts suggest its involvement. A seroepidemiological investigation was therefore conducted as a case-control study to compare the seroprevalences of BHV-4 infections in the aborted-cow population and in a randomly selected control group in the province of Liège (Belgium). The seroprevalence (17.2%) in aborted cows was significantly higher than that of the control group (10.0%). The odds ratio (OR) was 1.87 (1.06 < 3.30). BHV-4 infection is therefore considered as a risk factor for abortion in cows.     

Limitations of serodiagnosis in chlamydial genital tract infections

Infection with Chlamydia trachomatis results in the formation of a variety of antibodies with group, species, subspecies and serovarspecificity. Sera from patients with genital tract infections often show broad reactivity in serological tests. This may be due to the presence of cross-reacting antibodies, repeated infections by different serotypes or concurrent genital and respiratory infections by different chlamydial species. Other factors contributing to difficulties in interpretation include how antibody titres in acute mucosal infections, the occurrence of latent infections and reactivations, and the persistence of IgG which does not allow the differentiation of past from current infections. For these reasons, serology alone is inadequate for the diagnosis of uncomplicated lower genital tract infections. In upper genital tract infections, however, because of difficulties with sampling from the infected site, a positive serology may be the only indications of chlamydial involvement. This paper discusses the principles of chlamydial antibody assays, difficulties with their interpretation and their role in the diagnosis of upper and lower genital tract infections.     

Human papillomatous virus infection update: impact on women's health

Human papilloma virus (HPV) is one of the sexually transmitted diseases (STDs) seen throughout the population. More than 60 types of HPV have been identified, and 20 are known to cause genital warts; other types of HPV have an oncogenic potential. During pregnancy, genital warts may grow (possibly due to a suppressed immune system) and the neonate may become exposed. Several cofactors that have been identified in the development of HPV include oral contraceptive use, pregnancy and parity, nutrition, smoking, unsafe sex practices, and immunosuppression. Treatment options are aimed at destroying the visible lesions and include topical therapy, laser vaporization, cryocautery, liquid nitrogen, or simple excision. Health care providers have an important role in counseling about HPV infections. This includes educating clients about risk factors, prevention, signs and symptoms of STDs including HPV, safe sex practices, and the importance of regular examinations. Empowerment and a positive approach must be taken to help the client understand that she has a right to protect herself from STDs including HPV.     

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.