The Impact of Sexually Transmitted Infections (STIs) on Women’s Health

by Orla Blundell, AWG Languedoc-RoussillonF

Key Facts and Figures:

  • Worldwide, there are more than 1 million sexually transmitted infections (STIs) acquired every day.
  • Each year, there are an estimated 357 million new infections.
  • More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact.
  • 8 of these pathogens are linked to the greatest incidence of sexually transmitted infection. Of the 8 most common infections, 4 are, at present, curable: syphilis, gonorrhoea, chlamydia and trichomoniasis, whereas 4 are viral infections and are incurable: hepatitis B, herpes simplex virus (HSV or herpes), HIV, and human papillomavirus (HPV).
  • More than 500 million people are estimated to have genital infection with herpes simplex virus (HSV).
  • More than 290 million women have a human papillomavirus (HPV) infection (1).
  • In 2012, more than 900 000 pregnant women were infected with syphilis resulting in approximately 350 000 adverse birth outcomes including stillbirth (2).
  • In some cases, STIs can have serious reproductive health consequences beyond the immediate impact of the infection itself (e.g., infertility or mother-to-child transmission) In the US, undiagnosed STIs cause 24,000 women to become infertile each year (3).
  • Drug resistance is a major threat to reducing the impact of STIs worldwide (4).

Introduction:

Sexually transmitted infections (STIs), sometimes referred to as sexually transmitted diseases (STDs), are generally acquired via vaginal, anal, or oral sexual contact. An STI is defined as an infection that results from the transmission of a pathogenic organism by sexual contact and denotes a perceptible illness in the general population or in a defined subpopulation. Although there is no consensus on when each of these terms should be used and whether or not they are interchangeable, the American Sexual Health Association (ASHA) makes a distinction- stating that  "a disease", as in STD, indicates a clear medical problem, usually with signs or symptoms; but as most people infected with one or other of the most common STIs do not manifest signs or symptoms, or have very mild symptoms, I will therefore employ the term STI.

Female symptoms of an STI can include vaginal itching, rashes, changes in urination, unusual discharge and abdominal and/or pelvic pain, although as mentioned many STIs display relatively few or no symptoms at all. In fact, it is estimated that as many as 1 in 5 Americans has genital herpes, yet up to 90% of those infected are completely unaware they have it. If STIs are left undiagnosed or untreated, they can have serious consequences — in particular fertility problems and an increased risk of cervical cancer. Additionally, they may increase the possibility of complications for example abdominal pain or ectopic pregnancy. When women experience symptoms of an STI, they may often be mistaken for indications of something else, such as a urinary tract or yeast infection.  Therefore, it is imperative to get tested in order to obtain treatment for the correct infection.

Women ought to be aware of possible STI symptoms so that they can seek medical advice if necessary. The common symptoms are as follows:

Changes in urination: Pain or burning sensation when urinating, an increased frequency of urination or the presence of blood in the urine can all indicate the presence of an STI.

Abnormal vaginal discharge: The appearance, amount and consistency of vaginal discharge vary throughout a woman’s cycle.  A thick, white discharge can be indicative of a yeast infection, whereas a yellow/green discharge is more likely a sign of gonorrhea or trichomoniasis.

Vaginal Itching: Itching is a very non-specific symptom and may not be related to an STI or indeed even be the result of something serious. The sex-related sources of vaginal itching include allergic reactions to latex condoms, yeast infection, pubic lice or scabies, genital warts or may suggest the early stages of bacterial and viral STIs.

Pain during sex: This symptom is frequently ignored, but abdominal or pelvic pain can be a sign of pelvic inflammatory disease (PID) regularly caused by an advanced infection with either chlamydia or gonorrhea.

Abnormal bleeding: Abnormal and/or breakthrough bleeding is another potential indicator of PID or further reproductive problems resulting from an STI.

Rashes or sores: Sores or tiny pimples round the mouth or vagina can indicate herpes, HPV, or syphilis.

Common STIs in Women

Human papillomavirus (HPV) is the name for a group of viruses that can affect the skin, but more predominantly affects the moist mucus membranes lining the body, which include the cervix, anus, mouth and throat. Whilst there are more than 100 forms of HPV, approximately 30 of these are responsible for genital HPV infection. Nevertheless, these infections are common and highly contagious. Infection with some types of genital HPV may produce genital warts, abnormal tissue growth and changes to cells within the cervix – which can sometimes precede cervical cancer. Cervical cancer is the fourth most common cancer in women globally, and almost all cervical cancer cases (99%) are associated with genital HPV infection. https://www.cdc.gov/hpv/parents/whatishpv.html

Vaccination and Treatment: Girls aged 11 to 13 are offered a vaccination against HPV in order to offer protection against types of HPV that can lead to cervical cancer. Vaccination is not currently recommended for women over 26 years as clinical trials have demonstrated that little or no protection against disease was afforded in this age group. For more information and guidelines on the HPV vaccine, please access the website of the Centers for Disease Control and Prevention.  The recommended advice for women between ages 25-64 for prevention of cervical cancer is to be routinely screened to check for abnormal cells in the cervix. The choice of treatment for HPV-related warts will depend on findings on examination and patient preference. As warts often resolve spontaneously in around a third of patients, sometimes there is no need to treat. All other treatments have significant failure and relapse rates, and occasionally can trigger local skin reactions. Soft non-keratinised warts respond well to locally administered products containing podophyllotoxin and trichloroacetic acid (TCA), whereas keratinised lesions are better treated with physical ablative methods such as cryotherapy (liquid nitrogen), excision, or electrocautery. If there are only a small number of warts present, either ablative or topical podophyllotoxin therapies can be employed from the onset. Surgery is generally considered for very large lesions.

Herpes Simplex Virus

Herpes simplex viruses, more simply herpes, are categorized into two types: herpes type 1 (HSV-1, or oral herpes) and herpes type 2 (HSV-2, or genital herpes). Most commonly, herpes type 1 causes sores around the mouth and lips (fever blisters or cold sores). HSV-1 can cause genital herpes, but most cases of genital herpes are caused by herpes type 2. In HSV-2, the infected person may have sores around the genitals or rectum.  HSV-1  is transmitted through oral secretions or sores on the skin, and is spread through kissing or sharing objects such as toothbrushes or eating utensils. However, a person can only be infected with herpes type 2 infection during sexual contact with someone who has a genital HSV-2 infection.  Both HSV-1 and HSV-2 can be spread even if sores are not present. Treatment for genital herpes is with antiviral drugs which can reduce the severity and duration of symptoms but will not cure the infection. The three major drugs commonly used to treat symptoms include: acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex) are taken orally with severe cases requiring intravenous (IV) acyclovir.

Hepatitis B

Hepatitis B is an infection of the liver by a virus transmitted via blood and body fluids. It doesn’t usually cause problems or symptoms in adults and will normally resolve within a few months without treatment; but in children, the virus often persists for years and can eventually result in serious liver damage. For people from high-risk countries, for those who inject drugs and people who have unprotected sex with multiple sexual partners and are at risk, a hepatitis B vaccine is available.

Many people with hepatitis B are symptomless and fight off the virus not realising they have had it. If symptoms do develop, normally within two to three months after exposure, these may include flu-like symptoms — tiredness, fever, general aches and pains, loss of appetite, nausea, diarrhoea, jaundice — and will generally subside in one to three months (acute hepatitis B), although rarely the infection can last for six months or longer (chronic hepatitis B). Hepatitis B, though, can cause serious liver damage if left untreated, so you should get medical advice if you think you may have been exposed to the virus. If you've been exposed to Hep B in the past few days, emergency treatment may stop you becoming infected; an infection lasting a few weeks or months (acute hepatitis B) may only require symptomatic relief treatment while your body fights the infection. If you've had the infection for more than six months (chronic hepatitis B), you may be offered treatment that can keep the virus under control and reduce the risk of liver damage. Chronic hepatitis B often requires long-term or lifelong treatment and regular monitoring to check for any further liver problems.

Read more about hepatitis B vaccination.

HIV (Human Immunodeficiency Virus)

HIV has been covered extensively in a previous HealthTeam article.

Chlamydia, Gonorrhea and Trichomoniasis and Syphilis

The World Health Organization (WHO) has provided estimates of the global and regional prevalence of the four curable STIs (chlamydia, gonorrhoea, trichomoniasis and syphilis) approximately every 5 years since 1995, as the majority of STI public health interventions are focused on these infections. Quantifying the prevalence and incidence of infection is vital for the development of program interventions and for promoting these programs so that resources can be ascribed appropriately. In addition, as these infections are curable, estimating incidence rates can provide insight into the potential impact of STI prevention and management strategies.

And to view a National Report on the prevalence of the most commonly acquired STIs, compiled by the Surveillance and Data Management Branch of Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention in 2017, see https://www.cdc.gov/std/stats17/natoverview.htm.

Chlamydia

Chlamydia is a common and curable infection caused by the bacteria chlamydia trachomatis and represents the most common bacterial sexually transmitted infection (STI) in the US, particularly among sexually active adolescents and young adults. In 2017, a total of 1,708,569 cases of the disease were reported to the CDC which corresponds to a rate of 528.8 cases per 100,000 population, an increase of 6.9% compared with 2016. Increased rates of chlamydia have been reported in both males and females (although reported cases in men are generally lower than in women, a reflection of the larger number of women screened), among all racial and Hispanic ethnicity groups, and in all regions of the US.  Most women with chlamydia (and about half of men) do not experience symptoms. Since symptoms may not be present, the only way to know if a person who may be at risk is infected is to be tested. Annual testing for the infection is recommended for all sexually active women age 25 and under, and is also recommended for women over age 25 who are at risk (e.g. those with new or multiple sex partners).

Gonorrhea

In 2017, a total of 555,608 cases of gonorrhea were reported to CDC, and it is therefore the second most common notifiable complaint in the US. There was a 75.2% increase in reported cases since an historic low in 2009. Gonorrhea is caused by infection with the bacterium Neisseria gonorrhoeae. If the infection is not promptly treated, the bacteria can readily advance into the reproductive tract to the uterus, fallopian tubes, ovaries, and surrounding structures causing PID. There is also a chance that scar tissue will form, and it increases the risk of a tubal or ectopic pregnancy. Pregnant women who have gonorrhea are at increased risk of miscarriage and inflammation of the lining of the uterus after childbirth, and further problems may be experienced during delivery of a baby; in particular, a baby’s eyes may become infected whilst passing through the birth canal. Additionally, a baby infected with gonorrhea is at risk of developing a blood infection (sepsis) which can lead to arthritis, brain and spinal cord infection. Gonorrhea infection is treated with antibiotics, although antimicrobial resistance has become an important consideration in the treatment; and ceftriaxone and azithromycin antibiotic therapy is currently the only CDC recommended treatment for gonorrhoea.

Syphilis

When we think of syphilis, we often call to mind a disease of centuries old, and presume that it is not as common today.  However, in 2017, a total of 30,644 cases of primary and secondary syphilis, the most infectious phases of the disease, were reported in the US, giving a rate of 9.5 cases per 100,000 population. Since a historic low in 2000 and 2001, the rate of syphilis has increased almost every year, with an increase of 10.5% during 2016–2017. Syphilis is caused by infection with the bacterium Treponema pallidum subspecies pallidum with transmission by direct contact with an infectious lesion or by transmission during pregnancy. Syphilis, however, predominates among white MSM (men who have sex with men) aged 25–34, many of whom (40%) are HIV-1 co-infected and the rise in rates between 2000 and 2017, are principally attributable to increased cases among men. Treatment is generally with Benzathine penicillin G given as a single intramuscular injection or alternative antibiotic regimens administered orally including doxycycline, ceftriaxone, amoxycillin or azithromycin generally over a 10 or14 day period.  In 2017, in the United States, there were a total of 918 reported cases of congenital syphilis, including 64 stillbirths and 13 infant deaths. The national rate of 23.3 cases per 100,000 live births represents a 43.8% increase compared with the rate in 2016.

Trichomoniasis

Trichomoniasis, or "trich", is also a common STI caused by an organism called Trichomonas vaginalis.  Most people are asymptomatic although some women may experience itching, burning, redness or soreness of the genitals, discomfort on urination, a thin discharge with an unusual smell that can be clear, yellowish or greenish. Being infected with trich makes it easier to become infected with the HIV virus. If you are pregnant and have trich, you are at increased risk for premature rupture of membranes, preterm delivery, and delivery of a low birthweight baby.

Treatment of Bacterial STIs

These STIs are all bacterial and as such are treated with antibiotics. The drugs are usually administered orally as tablets or capsules, but also may be administered by injection. The choice of drug, dosage and the length of treatment will depend on the severity of the infection, whether you are pregnant or breast-feeding, have an allergic reaction to an antibiotic, and whether you have been treated for sexually transmitted infections in the past.

 It is essential that all of your sex partners be tested and, if necessary, treated for infection and all sexual contact should be avoided until treatment is finished and all evidence of disease has been eliminated. For more information on Chlamydia, Gonorrhea, Syphilis and Trichomoniasis you can visit the following sources: Centers for Disease Control and Prevention www.cdc.gov/std or American Sexual Health Association (ASHA) www.ashastd.org.

Prevention and Protection and Communication

Everyone should have the opportunity to make informed choices about their health and wellness. Honest communication about sexual activity and sexual history with partners, and health care professionals is essential in preventing transmission and for effective treatment and eradication of infections. Individuals, working with health care providers and committed public and private organizations, can be proactive in the prevention of STIs and the related health consequences. Health care professionals together with federal, state and local community support teams can provide education on STIs and communicate the need for regular testing. Parents can better educate their children about STIs and sexual health. Individuals should use condoms consistently and correctly, and openly discuss preventative measures and behaviors to protect their health. Female condoms and dental dams can provide a certain level of protection, although opinions are still divided as to whether they are as effective as the male condom in preventing transmission of infections.

Some women may develop an STI as a direct result of a sexual assault. In these circumstances, the healthcare provider will try obtain DNA samples of the perpetrator, evaluate the victim’s injuries and will do a full screen for potential STIs. Even if some time has passed since an assault has taken place, medical care should ideally still be sought to discuss health-related concerns and follow-up. Depending on the person and their individual risk factors and medical history, the healthcare provider may prescribe preventative treatment, including antibiotics, a hepatitis vaccine, an HPV vaccine or HIV antiviral medication.

Conclusion

In conclusion, the global prevalence and incidence of STIs remains high, with nearly one million new cases of a potentially curable STI acquired every day. There is an essential requirement to improve the monitoring of STI incidence and prevalence, together with the global changes and patterns in the data.  This is particularly important with regards to the design and implementation of STI interventions, and will help in advocating for funding for programs and research into the development of more efficacious therapeutics, point-of-care diagnostics, better and less expensive vaccines appropriate for global use.

References

(1) Worldwide prevalence and genotype distribution of cervical human papillomavirus DNA in women with normal cytology: a meta-analysis.
de Sanjosé S, Diaz M, Castellsagué X, Clifford G, Bruni L, Muñoz N, et al. Lancet Infect Dis. 2007 Jul;7(7):453-9.

(2) Global Estimates of Syphilis in Pregnancy and Associated Adverse Outcomes: Analysis of Multinational Antenatal Surveillance Data
Newman L, Kamb M, Hawkes S, Gomez G, Say L, Seuc A, et al. PLoS Med 10(2): e1001396. doi:10.1371/journal.pmed.1001396

 (3) Hamblin, J., 2013. 24,000 U.S. Women Become Infertile Every Year From Undiagnosed STIs, https://www.theatlantic.com/health/archive/2013/04/24-000-us-women-become-infertile-every-year-from-undiagnosed-stis/274666/

(4) https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis)

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