Chlamydial infection of the urogenital tract in promiscuous and non-promiscuous women

Chlamydia trachomatis and oral contraceptive use: a quantitative review

OBJECTIVES

Chlamydia trachomatis is now recognised as a major sexually transmitted disease; oral contraceptive use is rapidly increasing particularly in developing countries. There are thus important public health implications of the many reports that isolation of C trachomatis is more frequent among users of oral contraceptives. The aim of this analysis was to assess the strength and consistency of this association by summarising published studies between 1972 and 1990.

DESIGN

Studies identified were grouped according to whether they were prospective or case-control studies. Data were extracted and pooled estimates of the unadjusted odds ratios were made for all studies, as well as for sub-groups defined by an index of study quality, background prevalence of C trachomatis, and the contraceptive comparison being made.

LOCATION

Studies in the analysis were mainly conducted in Europe and North America; the meta-analysis was done at the Harvard School of Public Health, Boston, MA, USA.

RESULTS

The pooled estimated unadjusted odds ratio for 29 case-control studies examined was 1.93 (95% CI, 1.77-2.11), indicating an almost twofold increased risk of chlamydial infection for oral contraceptive users. Neither study quality nor prevalence of C trachomatis modified this risk. When compared to the use of barrier contraceptives, however, the risk of infection for women using oral contraceptives increased to 2.91 (95% CI, 1.86-4.55). The pooled estimated protective effect of barrier methods in these studies was 0.34 (95% CI, 0.22-0.54).

CONCLUSIONS

Cross-study comparisons of the relationship between oral contraceptive use and chlamydial infection are limited by the design and analysis of many component studies which did not control for confounding factors such as sexual behaviour and age. The almost twofold risk of increased chlamydial infection for oral contraceptive users, supported by the findings of two prospective studies, however, points to the importance of considering the risks and benefits of oral contraceptive use in women who are likely to be exposed to C trachomatis and other STDs. The protective effect of barrier methods emphasizes the continued need for promoting barrier methods of contraception.

Aetiology of urinary symptoms in sexually active women

Two hundred and fifty six unselected women, 50 of whom had urinary symptoms (frequency of urination or dysuria, or both), and who were attending a department of genitourinary medicine, were investigated. The urinary symptoms were associated both with pyuria and the isolation of undoubted pathogens from midstream urine (MSU) specimens. No associations were found between urinary symptoms and the isolation of Neisseria gonorrhoeae or Chlamydia trachomatis from the urethra or cervix; the recovery of Mycoplasma hominis from the urethra, cervix, or MSU; the recovery of Trichomonas vaginalis or Candida albicans from the vagina; or the presence of bacterial vaginosis. Urethral leucocytosis was associated with the isolation of T vaginalis but not with the recovery of N gonorrhoeae, C trachomatis, C albicans, or urinary pathogens. Pyuria was associated with the isolation of urinary pathogens and with the presence of trichomoniasis; it was not associated with the recovery of C trachomatis or M hominis.

Chlamydial infections of the urethra in women

Cervical and endourethral swabs from 360 untreated women attending a sexually transmitted disease (STD) clinic were cultured for Chlamydia trachomatis and other genitourinary pathogens. The patients included contacts of men with non-gonococcal urethritis, women with gonorrhoea, and those in whom symptoms suggestive of urinary tract infection were the main reasons for their attendance. Chlamydial infection of the urethra was less common than, and seldom occurred in the absence of, cervical chlamydial infection; it was frequently silent, producing no signs or symptoms of urethritis. Only 33/96 women with evidence of urethritis gave chlamydia positive urethral swabs, and 14 of them had other concurrent infections of the genitourinary tract. Chlamydia trachomatis thus does not appear to be a major cause of the signs and symptoms of urethritis commonly found in women attending STD clinics, and there seems to be no indication for taking routine urethral swabs to aid in the diagnosis of chlamydial infection in women.

Prevalence of chlamydial infection in promiscuous women

Chlamydia trachomatis was isolated from the cervix of 18 (33%) of 55 women who admitted to two or more casual sexual contacts to one (3%) of 32 women who admitted to one casual contact in the preceding month. The chlamydial infections did not produce characteristic clinical features. Since promiscuous women are at high risk of acquiring chlamydial infection, they should be regarded as a priority group when resources for chlamydial isolation are limited.

Chlamydial infection: a common sexually transmitted disease

Chlamydia trachomatis infection is more prevalent than gonorrhea and causes a similar clinical picture. It is the prime cause of non-gonococcal urethritis in men and pelvic inflammatory disease in women. Its sequelae in women are ectopic pregnancy and infertility. It can be transmitted from an infected mother to her newborn child, leading to inclusion conjunctivitis and pneumonia. Tetracycline and erythromycin are effective in eradicating chlamydial infections, but the penicillins are not. Screening of high risk groups and special diagnostic facilities would help control this common sexually transmitted disease.

Chlamydial screening of pregnant women in a sexually transmitted diseases clinic

Fifty-three consecutive pregnant women seen over six months were screened for chlamydial infection, syphilis, gonorrhoea, trichomoniasis, and candidosis. Chlamydia trachomatis was isolated in 20 (37.7%) patients, of whom six were sexual partners of known cases of non-gonococcal urethritis (NGU) (two had associated gonorrhoea or candidosis) and six had gonorrhoea (three had associated trichomoniasis and candidosis). If treatment is given to contacts of NGU 14 patients with other presenting conditions would not have been treated unless chlamydial cultures had been performed. This may lead to potentially serious complications of chlamydial infection in both mothers and neonates.

Cytological and histopathological abnormalities of the cervix in genital Chlamydia trachomatis infections

Since genital infection with Chlamydia trachomatis may be associated with cervical abnormalities 160 patients with grandular ectopia attending a gynaecological outpatient clinic were examined for antibodies against C trachomatis, the presence of C trachomatis infection, and cytological and histopathological abnormalities of the cervix.A significantly higher incidence of histological dysplasia was found in women with glandular ectopia who had antichlamydial antibodies than in those without.

Oral contraceptive use and prevalence of infection with Chlamydia trachomatis in women

One thousand eight non-pregnant women aged 16-34 years, presenting for the first time at a clinic for sexually transmitted diseases (STD), were examined and screened for infection with Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Candida species. The respective prevalence rates were 21.1%, 20.7%, 13.4%, and 27.8%. Isolation rates for C trachomatis, either occurring alone or in association with other genital infections, were significantly greater in women using oral contraceptive agents. This was not because oral contraceptive users were more promiscuous. The findings strengthen the case for providing a routine chlamydial culture service for women attending STD clinics. They also indicate that the likelihood of chlamydial infection in women taking oral contraceptives is increased.

Epidemiology of infection by serotypes D to K of chlamydia trachomatis

Non-specific urethritis (NSU) is a sexually transmitted disease; 50% of cases are due to Chlamydia trachomatis, so that this is the commonest sexually transmitted infection in the developed world. Chlamydial infection is now readily diagnosable and the evidence increasingly suggests that it is underdiagnosed. Chlamydial conjunctivitis (in the newborn baby or the adult) in the developed world is a complication of sexually transmitted genital infection by C trachomatis and it indicates a large reservoir of such infections. Because of the association of sexually transmitted diseases, systemic treatment for such chlamydial conjunctivitis should not be given until full genital and serological investigators have been carried out. Chlamydial infection causes serious complications (that were formerly often thought to be gonococcal), such as epididymitis in young men and salpingitis on young women. It may cause local complications in the eye of the newborn baby and even pneumonia in babies and fatal endocarditis in adults. The diagnosis of NSU should lead to the correct treatment of the male patient and of his sexual partners. It is the promiscuous woman, who does not have a regular sexual partner to report back to her that he has NSU, who is at particular risk of undiagnosed chlamydial infection. Routine genital investigations for chlamydia are particularly indicated in her case. Following the parallel of gonorrhoea, it seems that the use of contact tracers may be an effective method for controlling chlamydial infection.

The rôle of Chlamydia trachomatis in genital-tract and associated diseases

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The need for a chlamydial culture service

In a prospective study of unselected, female patients attending a sexually transmitted disease clinic one in eight patients would have been errouneously declared free of infection in the absence of a chlamydial culture service. Chlamydia trachomatis is now accepted as a causative organism of non-specific urethritis and post-gonococcal urethritis in men and non-specific genital infection in women. Thus, facilities for isolation of C. trachomatis should be an essential aid in the management of women attending STD clinics. Male patients would also benefit if such facilities were readily available.

Role of Chlamydia trachomatis in non-acute prostatitis

The possible role of Chlamydia trachomatis in non-acute prostatitis was investigated by cultural and serological techniques in a study of 53 adult males. C. trachomatis was isolated from the urethra of only one of the 53 patients and from none of the 28 specimens of prostatic fluid from the same patients. By means of a modified microimmunofluorescent test, serum chlamydial IgG antibodies at a titre of 1/64 or greater, or IgM antibodies at a titre of 1/8 or greater, or both were detected in six of the patients, suggesting a recent or current chlamydial infection, while IgG or IgA antibodies at a titre of 1/8 or greater were detected in the specimens of prostatic fluid from two of the 28 men studied. In the seven patients with evidence of chlamydial infection, as well as in a further 13 of the 53 patients studied, the presenting symptoms suggested non-gonococcal urethritis (NGU) rather than prostatitis. Thus in this study C. trachomatis would appear to play a minor aetiological role, if any, in non-acute prostatitis.