Chlamydia in Women: a Case for More Action?

Abstract

The 1985 Communicable Disease Surveillance Center figures for sexually transmitted diseases document over 14,000 confirmed cases of genital chlamydial infection in women. Yet, this figure seriously underestimates the size of the problem as many chlamydial infections are silent. The mainstay of diagnosis until recently has been isolation of C. trachomatis in cell culture, which is time consuming, technically demanding, expensive, and available in only a few centers. A firm diagnosis of chlamydial infection cannot be based on serology alone. Antibodies can be detected in 78-100% of womn with C. trachomatis in the cervix, but in those who are culture negative 31-87% also will have antibodies. More support is given to the diagnosis by demonstration of a rising titre of IgG antibody or by detection of IgM, but because of the late presentation of most women with chlamydia this is seldom possible. Newer tests include direct immunofluorescence statining of genital secretions which is rapid and simple. Results of this method compare favorably with those of cell culture, but screening large numbers of smears is expensive and tedious. Enzyme-linked immunosorbent assays also give good results. C trachomatis is a well known cause of cervicitis and salpingitis and is consequently a major factor in infertility. The frequency of chlamydial infection is influenced by sexual activity and promiscuity, but the effect of contraceptive choice is more difficult to determine. An IUD can provide a nidus for many infections, but the role of oral contraceptives (OCs) is more controversial. Instrumentation of the endocervical canal provides a route for introduction of infection, which is therefore a frequent and important complication of induced abortion. Westergaard et al. in a study of women having 1st trimester abortions found that 10% had symptomless cervical chlamydia; postabortal pelvic inflammatory disease developed in 28% of these patients by comparison with 10% in culture-negative women. Other workers have found similar results. The role of chlamydia as a cause of morbidity in pregnancy is unclear. Complications for the newborn are better established. It has been estimated that between 2-37% of mothers will have a chlamydia infection in pregancy. If 33-50% of newborns at risk get conjunctivitis, and 10-20% get pneumonitis, this gives some indication of the extent of the problem. Several studies have suggested an association between cervical chlamydial infection, anti-chlamydial antibodies, and cervical dysplasia. Emphasis on early diagnosis and treatment is of paramount importance to reduce the prevalence of chlamydial infection and its complications; without this rates of ectopic pregnancy and infertility are bound to increase.