A sexually transmitted disease (STD/ STI) is an infection passed from partner to partner through sexual contact and can occur in the mouth, genitals and the anus. According to the US Department of Health and Human Services the United States has the highest rates of STDs in the industrialized world. In the US alone, an estimated 15.3 million new cases of STDs are reported each year and cross every socioeconomic level, educational level, age, race, ethnicity and religion. If left untreated, STDs can cause a number of serious complications that affect fertility, in women more significantly than in men. These complications include pelvic inflammatory disease (PID), chronic pelvic pain and ectopic pregnancy.
PID is an infection of the reproductive organs including the uterus, fallopian tubes and the ovaries resulting from an untreated sexually transmitted disease, most commonly, chlamydia and gonorrhea. It affects more than one million women annually and can cause infertility by scarring the fallopian tubes and interfering with sperm’s ability to fertilize an egg. Additionally, a partially blocked or damaged tube may cause a developing embryo to implant in the fallopian tube rather than moving into the uterus to implant, resulting in an ectopic pregnancy. Untreated, an ectopic pregnancy can rupture the fallopian tube causing severe pain, internal bleeding, and even death.
According to the Centers for Disease Control (CDC) sexually active women in their childbearing years are most at risk for PID. Those under age 25 are more likely to develop PID than those older than 25 because the cervix of teenage girls and young women is not fully matured and increases their chances to get the STDs commonly linked to PID. Other risk factors include:
- Multiple sex partners or a partner with multiple sex partners which increases the risk of transmission
- Douching which changes the vaginal flora (organisms that live in the vagina) in harmful ways and can force bacteria into the upper reproductive organs.
- Intrauterine Device (IUD) which increases the risk of transmission when the device is inserted
 The symptoms of PID can be vague and for that reason often go unrecognized and undiagnosed. If symptoms are present they may include: lower abdominal pain, fever, vaginal discharge that may have a foul odor, painful intercourse, painful urination, irregular menstrual bleeding, and rarely, pain in the right upper abdomen. Diagnosis is usually made based on clinical findings. Testing may include a physical exam; screening for STDs either with blood tests or vaginal cultures; abdominal or transvaginal ultrasound to check for an abscess and tubes that are blocked or filled with fluid; endometrial biopsy to check the lining of the uterus; and sometimes a surgical procedure (laparoscopy) is indicated to confirm the diagnosis by looking at the pelvic organs and taking a tissue sample. The scarring that results from PID can also cause abscesses to form and chronic pelvic pain. It is important to note that repeated episodes of PID increases the risks of infertility, ectopic pregnancy and chronic pelvic pain.
PID can be treated with antibiotics but will not reverse the damage to the reproductive organs already caused by the infection. For that reason any woman with the risk factors listed who has even vague symptoms of PID should seek professional care as soon as possible. Drug therapy with at least two broad spectrum antibiotics is usually indicated because of the difficulty identifying the organisms and because more than one germ may be responsible for the infection. These drugs may be given orally or by injection and it is crucial that the full course of antibiotics be taken. Moreover, all sexual partners (whether or not they have symptoms) should be informed and must be treated as well to prevent re-infection and all parties should be rechecked for infection once the treatment is completed.  The CDC recommends hospitalization to treat PID if the woman:
(1) Is severely ill (e.g., nausea, vomiting, and high fever)
(2) Is pregnant
(3) Does not respond to or cannot take oral medication and needs intravenous antibiotics
(4) Has an abscess in the fallopian tube or ovary (tubo-ovarian abscess).
If symptoms continue or if an abscess does not go away, surgery may be indicated.
CDC list of STDs include:
Bacterial vaginosis:
Bacterial vaginosis, (BV) is the most common vaginal infection in women of childbearing age and occurs when the balance of “good” bacteria normally contained in the vagina is disrupted and replaced by an overgrowth of certain “harmful” bacteria. BV is treated with antibiotics, either metronidazole or clindamycin and typically, male sex partners of women with BV do not need to be treated.
Genital Herpes
Genital herpes is caused by the herpes simplex viruses (HSV) type 1 and type 2. Most genital herpes is caused by HSV type 2. About 45 million Americans have genital herpes and it’s estimated that up to one million people become infected each year. There is no cure for genital herpes however certain drugs such as acyclovir, valacyclovir, and famciclovir can shorten outbreaks, make them less severe, or stop them from happening.
Chlamydia
Chlamydia is the most frequently reported STD in the US with an estimated 2.8 million Americans infected each year. Chlamydia is known as a "silent" disease because 75 percent of infected women and at least half of infected men have no symptoms. If left untreated approximately 40% of women will develop pelvic inflammatory disease (PID). The most commonly used medications to treat and cure chlamydia include a single dose of azithromycin or a course of doxycycline. All sex partners must be treated to avoid re-infection and sexual contact avoided until the course of antibiotics has been completed.
Trichomoniasis
Trichomoniasis is the most common curable STD in young, sexually active women. An estimated 7.4 million new cases occur each year in women and men. Trichomoniasis can usually be cured with the prescription drug, metronidazole, and all partners must be treated to prevent re-infection.
Gonorrhea
CDC estimates that more than 700,000 persons in the U.S. get new gonorrheal infections each year. In the United States, the highest reported rates of infection are among sexually active teenagers, young adults, and African Americans. Untreated gonorrheal infections can cause PID and increase the risk of ectopic pregnancy in women and epididymitis in men. Antibiotics can cure gonorrhea but the number of drug-resistant strains is increasing.
Hepatitis B (HBV)
The CDC reports one out of 20 people in the United States have been infected with Hepatitis B virus. (HBV) some time during their lives and n 2004 alone, an estimated 60,000 people were infected with HBV. HBV is spread by having sexual relations with an infected partner, exposure to infected blood from skin puncture or contact with mucous membranes. There are no medications for an acute HBV infection however there are antiviral drugs available for the treatment of chronic HBV infection. Hepatitis B vaccine is the best prevention against hepatitis B.  Human immunodeficiency virus (HIV)
HIV is the virus that causes AIDS and unlike most other viruses attacks the immune system. HIV destroys certain white blood cells (T cells or CD 4 cells) that the body needs to fight infection. AIDS stands for acquired immunodeficiency syndrome. AIDS is the final stage of HIV infection. CDC estimates that about 1 million people in the United States are living with HIV or AIDS. About one quarter of these people do not know that they are infected. The disease is spread by having sexual intercourse or sharing needles with an infected person. People diagnosed with an STD like syphilis are at increased risk for contracting HIV.
Human papillomavirus (HPV)
The CDC estimates that approximately 20 million people are currently infected with HPV and about 6.2 million Americans get a new HPV infection per year. Human papillomavirus is a group of viruses with more than 100 different strains; more than 30 of these viruses are sexually transmitted. Some viruses are called "high-risk" types, and may cause abnormal Pap tests and may also lead to cancer of the cervix, vulva, vagina, anus, or penis. Approximately 10 of the 30 identified genital HPV types can lead, in rare cases, to the development of cervical cancer. Most women are diagnosed based on abnormal Pap results, the primary cancer-screening test for cervical cancer or pre-cancerous changes in the cervix, many of which are related to HPV. An HPV DNA test is available and useful for women with Pap abnormalities to help determine the best course of treatment. An HPV vaccine is available and recommended for girls 11-12 years old as well as 13 – 26 year-olds not currently vaccinated.
Syphilis
According to the CDC over 32,000 cases of syphilis were reported in the US in 2002, including 6,862 cases of primary and secondary (P&S) syphilis. The incidence of infectious syphilis was highest in women 20 to 24 years of age and in men 35 to 39 years of age. Left untreated the disease progresses and can damage the internal organs and lead to paralysis, blindness, and dementia as well as other conditions that may be fatal.
Additional information on all of these can be found on the CDC websites listed below.
Prevention of sexually transmitted disease-related infertility starts with awareness. In 1993 Congress appropriated funds to support the development of an Infertility Prevention Program by establishing chlamydia screening programs for women across the country. Chlamydia is the most frequently reported STD in the US and government officials estimate that 2.8 new infections occur each year, a number that is likely under-reported due to the absence or vagueness of the symptoms. There are numerous CDC websites on the Internet with information and clinic sites where testing is offered.
Knowing the risk factors for contracting STDs may not be enough however. A recent analysis of a survey known as Project SAFE suggested that even with baseline counseling only half the women in the study group reported concern for future fertility. Based on these findings the authors advise that women in particular need to be informed about the correlation between sexual behavior and future fertility as well as how to discuss STDs and safe sex practices with their sexual partners.
The most reliable ways to avoid infection and prevent the spread of STDs include the following:
1. Abstaining from all forms of sexual intercourse
2. Being in a monogamous relationship with an uninfected partner
3. Using a latex male condom to reduce the risk of chlamydia, gonorrhea and trichomoniasis
4. Getting tested before starting a new relationship and asking your partner to be tested as well
5. Avoiding unprotected sex if your partner has any signs of a STD such as sores, rashes or a discharge.
6. Using a new condom for each sex act
7. Getting regular medical check-ups for STDs
For more information on this topic visit these websites:
American Social Health Association (ASHA): http://www.ashastd.org/
CDC National Prevention Information Network (NPIN): http://www.cdcnpin.org/scripts/index.asp
Cervical Cancer Awareness: http://www.cdc.gov/cancer/cervical/
Chlamydia: http://www.cdc.gov/std/Chlamydia/default.htm
Gonorrhea: http://www.cdc.gov/std/Gonorrhea/default.htm
HIV: http://www.cdc.gov/hiv/topics/basic/index.htm
STDs and Pregnancy: http://www.cdc.gov/std/STDFact-STDs&Pregnancy.htm
STD Prevention: http://www.cdcnpin.org/scripts/std/prevent.asp
Sexually Transmitted Diseases: http://www.cdc.gov/std/
References:
American College of Obstetricians and Gynecologists (ACOG). Pelvic Inflammatory Disease. ACOG Patient Education Pamphlet, 2007.
Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2002. MMWR 2002; 51(no. RR-6).
Champion J. Counseling about STIs: Lowering a woman’s risk. SRM 2007; 5: 29-32.
Chlamydia Prevalence Monitoring Project Annual Report 2005. Available at: http://www.cdc.gov/std/Chlamydia2005/CTSurvSupp2005Complete.pdf
Jensen JR, Shain RN, Holden AE, et al. Concern about the effects of STDs on future fertility can be learned and is associated with lower risk-taking behaviors in an inner-city minority population. Paper presented at: American Society for Reproductive Medicine 62nd Annual Meeting; October 24, 2006; New Orleans, La. Abstract O-127. In: Fertil Steril. 2006; 86(suppl 1):S54.
Koutsky LA, Kiviat NB. Genital human papillomavirus. In: K. Holmes, P. Sparling, P. Mardh et al (eds). Sexually Transmitted Diseases, 3rd edition. New York: McGraw-Hill, 1999, p. 347-359.
Kiviat NB, Koutsky LA, Paavonen J. Cervical neoplasia and other STD-related genital tract neoplasias. In: K. Holmes, P. Sparling, P. Mardh et al (eds). Sexually Transmitted Diseases, 3rd edition. New York: McGraw-Hill, 1999, p. 811-831.
Myers ER, McCrory DC, Nanda K, Bastian L, Matchar DB. Mathematical model for the natural history of human papillomavirus infection and cervical carcinogenesis. American Journal of Epidemiology 2000; 151(12):1158-1171.
Sexually Transmitted Diseases: Overview. Womenshealth.gov
Available at: http://www.4woman.gov/faq/stdsgen.htm
Westrom, L and Eschenbach, D. Chapter 58 In: K. Holmes, P. Mardh, P. Sparling et al (eds). Sexually Transmitted Diseases, 3rd Edition. New York: McGraw-Hill, 1999, 783-809. | 
