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Sexually transmitted diseases & women's health.

When Karen Engle,* then 25, went for a Pap smear in 1999, it had been two years since she'd had the routine test. The Seattle woman figured she didn't need one, since she hadn't been sexually active during that time. Now, after meeting the man she would eventually marry, she was in her doctor's office for a routine exam and birth control pill prescription. But when the results of her Pap came back, she was shocked.

Ms. Engle learned she had a highly advanced stage of cervical dysplasia -- a precursor to cervical cancer. The cause: Human papillomavirus infection (HPV), a sexually transmitted disease. Karen had never heard of the virus -- let alone the fact that it could cause cancer. Her condition was so severe, she required laser surgery to the inside and outside of her vagina, labia and cervix. She wound up hospitalized for a week as a result of laser burns, and today, 12 years later, still has substantial scarring in the floor of her vagina, making intercourse between her and her husband nearly impossible.

Even worse, she says, "I worry constantly that the virus will come back and I'll have to have yet another round of surgery. My Pap smears have yet to go back to normal after 12 years. Moreover, the stigma of having an STD has made it difficult for me to talk about it even with my friends." And it makes her angry that although HPV affects nearly one in four women on college campuses (and more than five million people each year), it is still not publicly discussed.

Yet HPV is the one of the most common sexually transmitted diseases in the U.S., second only to herpes. It causes nearly all cases of cervical cancer and, therefore, is directly linked to the 4,400 women who die of the disease each year. (1) Even more alarming: a recent study found that HPV infection may occur during a woman's very first sexual experience. (2) The virus' very prevalence, and the difficulty in avoiding it (even condoms are not wholly effective in protecting against HPV), led researchers in that study to conclude that "perhaps cervical human papillomavirus infection should now be considered an inevitable consequence of sexual activity. Certainly, no stigma should be attached to its acquisition. " (2)

That kind of thinking sends shivers down the spines of public health and other medical officials, who are dealing with what they call a hidden epidemic of sexually transmitted diseases--hidden because so many of the diseases, like HPV have no initial symptoms. Hidden also for another reason, says Stuart Berman, MD, who heads the U.S. Centers for Disease Control and Prevention's STD epidemiology and surveillance branch: "All these people are infected, but no one's talking to each other. Partners are not talking to partners, parents are not talking to kids, doctors are not talking to patients and patients are not talking to doctors."

An STD Epidemic

The STD epidemic is marked by more than 15 million new cases of STDs each year. These include the more common ones, such as HPV, chlamydia, herpes, hepatitis B and gonorrhea, as well as syphilis, HLV and trichomoniasis. (3)

"There's a sense that a lot of women are playing Russian roulette with their sexual health," says Beth E. Cheney, RN, MSN, CFNP, a nurse practitioner and the woman's health coordinator at Windham Hospital in Willimantic, CT. Ms Cheney directs the women's health clinic, which serves a high percentage of low-income and minority women.

At any one time, one-third to one-half of Ms. Cheney's patients has a sexually transmitted disease. But STDs are by no means limited to any socioeconomic or racial group. Recall the old Time magazine cover that called the viral STD herpes the "VD of the Ivy League." (4) And if you thought AIDS was still a gay man's disease, think again. "About 30 percent of all new infections are among women," says David Landry, MS, senior research associate at The Alan Guttmacher Institute in New York. Overall, women now account for more than 20 percent of all AIDS cases in the U.S., compared to just 14 percent in 1992. It's also the fifth leading cause of death for women age 25 to 44 and the third leading cause of death for African-American women in this age group. (5) In fact, African-American women have a tougher time with some STDs than Caucasian women. For instance, the rate of gonorrhea in African-American girls between the ages of 15 and 19 is 19 times higher than in Caucasian girls of the same age. (4)

Beyond race, however, the group that's most at risk of catching an STD is young women, particularly teenagers. Two thirds of those who contract an STD are 25 or younger. One study found that one in five adolescent girls had an undiagnosed STD. (7) There are two reasons for the high numbers, says Dr. Berman: young girls' sexual habits and their biology.

"Young women in general are probably at greater risk because of issues of serial monogamy," he says. That's when you stay with one sexual partner for awhile, then move onto another. Once you ye been with one person a few times, says Ms. Cheney, you begin to think they're "safe" and so may eschew precautions like the condoms you used during your first time with that person. And, as women put marriage further into their future, says Dr. Berman, the "age gap from when you begin menarche [menstruation] and may become sexually active, to when you get married and your risk of STDs dramatically declines, is the largest we've had in 100 years."

Anatomically, says Dr. Berman, young girls have a greater risk of acquiring chlamydia--the second most common STD--because they haven't fully matured. "When women are young, the lining of the uterus is more exposed," he says, providing a bigger target for chlamydial infections. As women age, the lining slides back into the uterus and exposure is reduced. Thus, it may take fewer exposures when you're young to actually catch the disease than when you're older, according to Dr. Berman.

Long-term Effects of STDs

But it's when you're older that chlamydia--and other STDs--can come back to haunt you. With HPV it's cervical cancer. "The issue is not so much getting it, but getting it and having it stay around for long periods of time," says Dr. Berman. Estimates are that more than 50 percent of all women are infected with the virus. The more partners a woman has, he says, the more likely the virus will "catch" and hang around longer after an initial infection. That's why regular Pap smears are so critical, says Thomas C. Wright, Jr., MD, director of GYN Pathology, College of Physicians and Surgeons at Columbia University in New York City. "We reduce your risk of cervical cancer by well over 90 percent," with regular Paps, he says. "Can you imagine any other public health screening program that reduces risk by 90 percent?"

Chlamydia, says Dr. Berman, "is a really nasty thing, because you may not know for 10 years that this infection did something bad to you." Ten to 20 percent of women with chlamydia or gonorrhea develop pelvic inflammatory disease (PID), which can lead to chronic pelvic pain, infertility and potentially fatal ectopic pregnancy. (8) "And," Dr. Berman says, "we're re starting to realize that it may be the infection that you get the second or third time that's most important and most responsible for causing damage to the reproductive system." Yet because both chlamydia and gonorrhea are bacterial STDs, they are easily treated with antibiotics, he says, and young girls all too often become reinfected. In fact, the greatest risk factor for getting chlamydia is a previous chlamydia infection. "Young people don't come away appreciating that they ducked a bullet," he says.

That bullet may be harder to avoid, at least with gonorrhea. A growing number of cases on the West coast, in Hawaii and in East Asian countries, are resistant to the most common class of antibiotics, fluoroquinolone, used to treat the disease. That resistance is expected to continue spreading eastward across the U.S.

STDs for Life

Get herpes--a viral infection--and you've got it for life. Just ask Meg *, a 46-year-old mother of two who was infected sometime in her 20s. Twenty years later, she still gets painful outbreaks when she's stressed--usually on top of terrible PMS. "You can just imagine how much fun that is," she says. At least Meg knows she has the disease and can avoid sex with her husband when she has an outbreak. Although at least 45 million people in the U.S. have genital herpes, most haven't been diagnosed. In fact, most genital herpes infections are transmitted by people who don't know they have the infection or who don't have symptoms when transmission occurs. (16) That was Meg's situation. "I just assumed the irritations were yeast infections or some other routine female thing," she says. "I have no idea how or from whom I contracted it--or how many people may have contracted it from me."

The ultimate risk of HIV--death--is fairly well known. But that doesn't stop sexually active women from taking chances. "Despite the campaigns and efforts to educate people, we're just not getting through, especially to the teen population," says Ms. Cheney. "I think there's just this sense of 'It won't happen to me."' And yet it does. It's estimated that at least half of all new HIV infections in the U.S. are among those under 25. The majority of young people with the virus are infected sexually. (9)

Ironically, the AIDS epidemic may, in part, be contributing to the STD epidemic. "Maybe in the wake of the AIDS epidemic people have not come to appreciate just how incredibly complicated these other diseases are," says Dr. Berman, "and that they run a far greater risk of getting them." And that, while STDs may not kill you, they will, by their very prevalence, negatively affect your life, he notes.

Pondering Prevention

Whenever Alvin F. Goldfarb, MD, professor of obstetrics and gynecology at Jefferson Medical College in Philadelphia, sees a teenage girl in his office, he asks her mother to wait outside. Then he quizzes the teenager: Do you have a boyfriend? Are you sexually active? What do you use for birth control? What about STD protection? Then, without question, he screens her for chlamydia and gonorrhea, and conducts a Pap to check for HPV. Then he has an incredibly blunt discussion with her about STDs. "I tell her, 'inspect the merchandise.' Look for pimples on the penis, any discharge."

"I believe very strongly in education, and in everyone knowing that they must be respectful of themselves and of anyone they're going to share their body with," he says. Unfortunately, Dr. Goldfarb, who is also the President and CEO of the Adolescent Wellness and Reproductive Education Foundation (AWARE), which attracts more than 16,000 visitors a month (most of them teens), knows that too few teenagers have someone like him in their life and so have no clue as to how to protect themselves from STDs.

Americans overall have misguided notions on how to protect themselves from STDs. In one study of 3,500 STD clinic visitors, nearly half believed douching protected against STDs, 20 percent thought birth control pills would do it and 16 percent thought washing their genitals after sex was effective. None of these approaches protects against STDs. In fact, irritation caused by douching may increase STD infection risk. (3) And testing for HIV does not prevent the disease, as more than 40 percent of women involved in a New York study believed. (10)

Your best bet? Abstinence and properly used latex condoms. The diaphragm may also provide some protection against gonorrhea, chlamydia and trichomoniasis. (16) Within the next few years, however, there may be a host of new weapons to fight STD transmission, including vaccines against chlamydia, HPV, genital herpes, gonorrhea and HIV, (12) and virus- and bacteria-killing gels, foams, creams or films, known collectively as topical microbicides. (13)
STDs At-A-Glance

 STD Type
Estimated Prevalence
 & Incidence Symptoms

* HPV (viral) Human papillomavirus infection (HPV)
 - 20 million people may cause genital warts, but
 currently infected generally doesn't cause symptoms.
 - 5.5 million new cases HPV infection can lead to cervical,
 annually penile and anal cancer. (16)

* Hepatitis B (viral) Symptoms may not occur at first;
 - 1.25 million people can cause loss of appetite, abdominal
 currently infected discomfort, nausea and vomiting, often
 - 140,000 to 320,000 progresses to jaundice. Eventually,
 new cases annually may cause liver failure. (1)

* HIV/AIDS (viral) Within 3 to 6 weeks of becoming
 - 800,000 to 900,000 infected: fever, joint pain, night
 people currently infected sweats, white patches in the mouth and
 - 40,000 (14) new cases throat, sore throat and skin rash; half
 annually of those infecteds show no symptoms.
 Other symptoms related to immune
 deficiency may not appear for 10 years
 or more

* Herpes Simplex Virus Small red blisters on the vulva, in
 (viral) the vagina and cervix that may bleed;
 - 45 million people flu-like symptoms. It can also make
 currently infected those infected with HIV more
 - 1 million new cases infectious. (8) Open lesions may
 annually increase the risk of sexual
 transmission of HIV.

* Gonorrhea (bacterial) Typically causes no symptoms; may
 - estimated number of cause thick, pus-like discharge from
 people infected N/A the vagina or urethra, frequent and
 - 650,000 new cases painful urination and pelvic pain
 annually during vaginal penetration. May
 increase risk of sexual transmission
 of HIV.

* Chlamydia (bacterial) Typically causes no symptoms; may
 - 2 million people cause vaginal discharge, vague lower
 currently infected abdominal discomfort and pelvic pain
 - 3 million new cases during vaginal penetration May
 annually increase risk of sexual transmission
 of HIV.

* Syphilis (bacterial) Symptoms include sores that mainly
 - estimated number of occur on the external genitals, vagina,
 people infected N/A anus or in the rectum, and a skin rash.
 - 70,000 new cases Sores also can occur on the lips and
 annually in the mouth. Transmission occurs
 during vaginal, anal or oral
 sex. (2) May increase risk of sexual
 transmission of HIV.

* Trichomoniasis (parasitic) Most infected women have an odorous,
 - estimated number of yellow-green discharge and irritation
 people infected N/A of the vaginal area. (15) May increase
 - 5 million new cases risk of sexual transmission of HIV. (8)
 annually

 STD Type
Estimated Prevalence
 & Incidence Treatment

* HPV (viral) External genital warts can
 - 20 million people be treated with topical
 currently infected medications, but infection
 - 5.5 million new cases may not be completely
 annually eliminated.

* Hepatitis B (viral) Antiviral medications such
 - 1.25 million people as alpha-interferon or
 currently infected lamivudine can treat chronic
 - 140,000 to 320,000 hepatitis B. (16)
 new cases annually

* HIV/AIDS (viral) Treatment can postpone or
 - 800,000 to 900,000 prevent the onset of AIDS.
 people currently infected Numerous antiretroviral
 - 40,000 (14) new cases drugs, including protease
 annually inhibitors. (16)




* Herpes Simplex Virus Antiviral medications such
 (viral) as acyclovir, famciclovir,
 - 45 million people valacyclovir, can treat and
 currently infected prevent outbreaks, but
 - 1 million new cases herpes cannot be cured. (8)
 annually


* Gonorrhea (bacterial) Various antibiotics,
 - estimated number of including ciprofloxin
 people infected N/A and ofloxacin (16)
 - 650,000 new cases
 annually



* Chlamydia (bacterial) Antibiotics such as
 - 2 million people azithromycin and
 currently infected doxycycline (16)
 - 3 million new cases
 annually


* Syphilis (bacterial) Penicillin (16)
 - estimated number of
 people infected N/A
 - 70,000 new cases
 annually




* Trichomoniasis (parasitic) Oral metronidazole (flaggl)
 - estimated number of is the recommended
 people infected N/A treatment. (16)
 - 5 million new cases
 annually

 STD Types
Estimated Prevalence
 & Incidence Prevention

* HPV (viral) Difficult to prevent if
 - 20 million people sexually active.
 currently infected Abstinence or monogamy
 - 5.5 million new cases with an uninfected
 annually partner reduces risk. (16)

* Hepatitis B (viral) A vaccine is available and
 - 1.25 million people recommended for those
 currently infected with risk factors (includes
 - 140,000 to 320,000 having several sexual
 new cases annually partners). (8)

* HIV/AIDS (viral) Condoms (16)
 - 800,000 to 900,000
 people currently infected
 - 40,000 (14) new cases
 annually




* Herpes Simplex Virus Condoms; abstaining from
 (viral) sex with infected person
 - 45 million people when lesions are visible,
 currently infected but infection can occur
 - 1 million new cases when there are no
 annually lesions. (16)


* Gonorrhea (bacterial) Condoms, diaphragm (15)
 - estimated number of
 people infected N/A
 - 650,000 new cases
 annually



* Chlamydia (bacterial) Condoms, diaphragm (15)
 - 2 million people
 currently infected
 - 3 million new cases
 annually


* Syphilis (bacterial) Condoms and avoiding
 - estimated number of sexual activity with
 people infected N/A someone with open
 - 70,000 new cases sores." (18)
 annually




* Trichomoniasis (parasitic) Condoms, diaphragm
 - estimated number of
 people infected N/A
 - 5 million new cases
 annually

Sources: U.S. Center for Disease Control and Prevention and American
Social Health Association, unless otherwise noted.


RESOURCES

Adolescent Wellness and Reproductive Education (AWARE) Foundation

1015 Chestnut Street, Suite 1225 Philadelphia, PA 19107-4302

215-955-9847

http://www.awarefoundation.org

Offers reproductive health education materials for teens, parents and educators.

Advocates for Youth

1025 Vermont Avenue, NW, Suite 200 Washington, DC 20005

202-347-5700

http://www.advocatesforyouth.org

Offers information to help teens make informed reproductive health decisions.

American Social Health Association

P.O. Box 13827 Research Triangle Park, NC 27709

1-800-361-8400

http://www.ahastd.org

CDC National STD Hotline: 1-800-227-8922

Provides basic STD information; coordinates CDC STD hotline.

Division of Reproductive Health

National Center for Chronic Disease Prevention and Health Promotion

4770 Buford Hwy, NE Mail Stop K20 Atlanta, GA 30341-3717

770-488-5200

http://www.cdc.gov/nccdphp/drh/index.htm

Publishes research-based reproductive health information on wide range of topics.

Girls Inc.

120 Wall Street New York, NY 10005-3902

1-800-374-4475

http://www.girlsinc.org

Develops educational programs to encourage girls to master physical, intellectual and emotional challenges.

HIV Over Fifty

http://www.hivoverfifty.org

Promotes access to educational and health care programs for persons over age 50 affected by HIV.

Sexuality Information and Education Council of the United States (SIECUS)

130 West 42nd Street, Suite 350 New York, NY 10036

212-819-9770

http://www.siecus.org

Develops and distributes reproductive health information for teens, parents, educators and health care professionals.

RELATED ARTICLE: The Basics of Birth Control and STDs

Although abstinence is the only sure way to protect yourself against an STD, condoms come in a close second. If your partner resists condom use, consider the female condom. Although no clinical studies have been completed to evaluate the role of the female condom in providing protection from STDs, if used correctly, it may substantially reduce the risk. (16)

Other birth control methods won't protect you from STDs, however. Vaginal spermicides containing nonoxynol-g (N-g) not only aren't effective in preventing gonorrhea, chlamydia or HIV, but frequent use has been associated with genital lesions, which may be associated with an increased risk of HIV transmission. While condoms can help prevent the spread of some STDs, they only work when they're used correctly:

* Use a new condom with each sexual act (including oral sex).

* Carefully handle the condom so you don't damage it with your fingernails, teeth or other sharp objects.

* Put the condom on after the penis is erect and before any genital contact.

* Use only water-based lubricants with latex condoms.

* Ensure adequate lubrication during intercourse.

* Hold the condom firmly against the base of the penis during withdrawal, and withdraw while the penis is still erect to prevent slippage. (16)

References

(1.) "HPV and Cervical Cancer Fact Sheet." Kaiser Family Foundation, Nov. 2001. http://www.kff.org

(2.) Collins, S. et al. "High incidence of Cervical Human Papillomavirus Infections in Women During Their First Sexual Relationship. BJOG, Jan. 2002, Vol. 109, 96-98.

(3.) "Counseling Can Help Correct misconceptions about Sexually Transmitted Diseases. Center for the Advancement of Health. [Press release]. Sept. 27, 2000.

(4.) Kaiser Family Foundation Reproductive Report, April 12, 2002.

(5.) "HIV/AIDS Among U.S. Women: Minority and Young Women at Continuing Risk." Fact sheet. U.S. Centers for Disease Control and Prevention (CDC). 2002. http://www.rdc.gov

(6.) "African Americans Disproportionately Affected by STDs." CDC. Dec. 5, 2000.

(7.) Wiesenfeld HC, Lowry DL, Heine RP, Krohn MA, Bittner H, Kellinger K, Shultz M, Sweet RL. "Self-collection of Vaginal Swabs for the Detection of Chlamydia, Gonorrhea and Trichomoniasis: Opportunity to Encourage Sexually Transmitted Disease Testing Among Adolescents." Sex Transm Dis. 2001 Jun; 28(6):321-5.

(8.) "Tracking the Hidden Epidemics: Trends in STDs in the U.S. 2000." CDC. http://www.cdc.gov

(9.) "New Resistant Gonorrhea Migrating to Mainland U.S." NY Times. May 7, 2002.

(10.) Rosenberg PS, Biggar RJ, Goedert JJ. "Declining Age at HIV Infection in the United States." [Letter]. New Engl J Med 1994;330:789-90.

(11.) "Women in a New York City Clinic Mistakenly Believe that HIV Testing is a Good Way to Prevent Infection." The Alan Guttmacher Institute. [Press release]. May 8, 2002.

(12.) "An Introduction to Sexually Transmitted Disease" Fact sheet. National Institute of Allergy and Infectious Diseases (NIAID). 1999. http://www.niaid.nih.gov

(13.) "NIAID Topical Microbicide Research Developing New Tools to Protect Women from HIV/AIDS and other STDs." Fact sheet. March 2000. http://www.niaid.nih.gov

(14.) "Older Americans Make Up the New Face of HIV/AIDS, Experts Say." Associated Press. May 11, 2002.

(15.) "The HIV/AIDS Epidemic in the United States." Fact sheet. Kaiser Family Foundation June 2001. http://www.kff.org

(16.) "Sexually Transmitted Diseases Treatment Guidelines," 2002. MMWR, May 10, 2002. CDC.

(17.) "Viral Hepatitis, Type B." Fact sheet. CDC. http://www.cdc.gov

(18.) "Some Facts About Syphilis." CDC. March 16, 2000. http://www.cdc.gov

(19.) "STDs and Pregnancy." Fact sheet. CDC. Oct. 1997. http://www.cdc.gov

* Not her real name
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Publication:National Women's Health Report
Geographic Code:1USA
Date:Jun 1, 2002
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Previous Article:Women's health screening guidelines.
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