Sexually transmitted diseases & women's health

National Women's Health Report, June, 2002

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."