STDs in Women and Infants in the U.S. - Slides

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Assessing Trends in Chlamydia Positivity and Gonorrhea Incidence and Their Associations with the Incidence of Pelvic Inflammatory Disease and Ectopic Pregnancy in Washington State, 1988-2010

BACKGROUND:

Chlamydia and gonorrhea screening for women is beneficial if it prevents serious reproductive sequelae, such as pelvic inflammatory disease (PID) and ectopic pregnancy (EP). We assessed trends in PID and EP among women in Washington and their association with gonorrhea incidence and chlamydia positivity in a screened population of women over a 23 year period.

METHODS:

Using data on chlamydia positivity from the Infertility Prevention Project, gonorrhea incidence from state surveillance, and PID and EP hospitalizations from hospital discharge records, we assessed trends in each condition over time. In addition, we estimated total incidence of PID and EP by incorporating information on outpatient-treated cases in alternative populations using a Bayesian approach that accounted for uncertainty in the estimates. We assessed associations between each infection and PID/EP using a linear regression model that accounts for year-to-year correlation in data points.

RESULTS:

We observed substantial declines in both infections and in each outcome over time. For every 2% decrease in chlamydia positivity, there was a 35.7/100,000 decrease in estimated total PID incidence (P = 0.058) and 184.4/100,000 decrease in estimated total EP (P = 0.149). For every 32/100,000 decline in gonorrhea incidence, there was a 16.5/100,000 decrease in total PID (P = 0.292) and 159.8/100,000 decrease in total EP (P = 0.020). The associations with inpatient PID and EP were highly significant for both chlamydia and gonorrhea.

CONCLUSIONS:

These ecological data note concurrent and substantial declines in chlamydia positivity and gonorrhea incidence, and in PID and EP incidence in Washington from 1988 to 2010 during a time when widespread chlamydia screening was ongoing.

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By:   Moore MS1, Golden MR, Scholes D, Kerani RP.

• 1From the *Department of Epidemiology, University of Washington School of Public Health, Seattle, WA; †Public Health-Seattle & King County, Seattle, WA; ‡Department of Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, WA; and §Group Health Research Institute, Group Health Cooperative, Seattle, WA. 

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Pelvic Inflammatory Disease associated with Chlamydia Trachomatis But Not Mycoplasma Genitalium in New Zealand

There is a paucity of studies looking at associations between Mycoplasma genitalium and pelvic inflammatory disease (PID). The objectives of this study were to estimate the prevalence of M. genitalium in women attending a sexual health service in New Zealand and secondly to examine for an association of M. genitalium with PID. 

Women consecutively attending the service for a sexual health screen (Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis) were recruited to establish a baseline prevalence of M. genitalium. An extra cervical swab was taken for the detection of M. genitalium. Recruitment of additional women with a clinical diagnosis of PID continued until a sufficient sample size was obtained to examine the association of PID with M. genitalium. Women in the baseline sample without PID were used as the control group. 

The control group included 250 women, with M. genitalium diagnosed in 8.7% (95% CI 5.8-12.9%) and C. trachomatis in 9.9% (95% CI 6.8-14.2%). Ninety-one women were recruited with PID; M. genitalium was diagnosed in 9.9% (95% CI 5.3-17.7%) and C. trachomatis in 27.5% (95% CI 19.4-37.4%). Multivariate analysis using clinically relevant variables showed that a diagnosis of C. trachomatis (OR 2.44, 95% CI 1.24-4.81) but not M. genitalium (OR 0.91, 95% CI 0.38-2.20) was significantly associated with a PID diagnosis. 

M. genitalium was almost as commonly diagnosed as C. trachomatis in this population. C. trachomatis was the only infection that was significantly associated with PID.

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By:  Jeannie Oliphant A B and Sunita Azariah A 

A Auckland Sexual Health Service, Greenlane Clinical Centre, Private Bag 92024, Auckland 1142, New Zealand. 

B Corresponding author. Email: jeannieo@adhb.govt.nz 

 

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Hysterectomy Risk in Premenopausal-Aged Military Veterans - Associations with Sexual Assault and Gynecologic Symptoms

Several gynecologic conditions associated with hysterectomy, including abnormal bleeding and pelvic pain, have been observed at increased rates in women who have experienced sexual assault. Previous findings have suggested that one of the unique healthcare needs for female military veterans may be an increased prevalence of hysterectomy, and that this increase may be partially due to their higher risk of sexual assault history and posttraumatic stress disorder (PTSD). While associations between trauma, PTSD, and gynecologic symptoms have been identified, little work has been done to date to directly examine the relationship between sexual assault, PTSD, and hysterectomy within the rapidly growing female veteran population.

To assess prevalence of hysterectomy in premenopausal-aged female veterans, compare to general population prevalence, and examine associations between hysterectomy and sexual assault, posttraumatic stress disorder (PTSD), and gynecologic symptoms in this veteran population.

We performed a computer-assisted telephone interview between July 2005 and August 2008 of 1004 female VA-enrolled veterans ≤52 years old from 2 Midwestern US Veterans Affairs medical centers and associated community based outreach clinics. Within the veteran study population, associations between hysterectomy and sexual assault, PTSD, and gynecologic symptoms were assessed with bivariate analyses using chi-square, Wilcoxon-Mann-Whitney, and t-tests; multivariate logistic regression analyses were used to look for independent associations. Hysterectomy prevalence and ages were compared to large civilian populations represented in the BRFSS and ACS NSQIP databases from the similar timeframes using chi-square and t-tests.

Prevalence of hysterectomy was significantly higher (16.8% vs 13.3%, p=.0002), and mean age at hysterectomy significantly lower (35 yo vs 43 yo, p<.0001), in this VA-enrolled sample of female veterans compared to civilian population-based datasets. Sixty-two percent of subjects had experienced attempted or completed sexual assault in their lifetimes. A history of completed lifetime sexual assault with vaginal penetration (LSA-V) was a significant risk factor for hysterectomy (age-adjusted OR 1.85), with those experiencing their first LSA-V in childhood or in military at particular risk. A history of PTSD was also associated with hysterectomy (age-adjusted OR 1.83), even when controlling for LSA-V. These associations were no longer significant when controlling for the increased rates of gynecologic pain, abnormal gynecologic bleeding, and pelvic inflammatory disease seen in those veterans with a history of LSA-V.

Premenopausal-aged veterans may be at higher overall risk for hysterectomy, and for hysterectomy at younger ages, than their civilian counterparts. Veterans who have experienced completed sexual assault with vaginal penetration in childhood or in military and those with a history of PTSD may be at particularly high risk for hysterectomy, potentially related to their higher risk of gynecologic symptoms. If confirmed in future studies, these findings have important implications for women's healthcare providers and policy makers within both the VA and civilian healthcare systems related to primary and secondary prevention, costs, and the potential for increased chronic disease and mortality.

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By: Ryan GL1, Mengeling MA2, Summers KM3, Booth BM4, Torner JC5, Syrop CH3, Sadler AG6.

• 1Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa; Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa. Electronic address: Ginny-ryan@uiowa.edu.
• 2Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region (VRHRC-CR), Iowa City VA Health Care System, Iowa City, Iowa.
• 3Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa.
• 4Center for Mental Healthcare Outcomes and Research, Central Arkansas Veterans Healthcare System and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
• 5Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa; Departments of Neurosurgery and Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa.
• 6Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa; Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa.  

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