What are RTIs?

RTIs include a variety of bacterial, viral, and protozoal infections of the lower and upper reproductive tracts of both sexes, and most of them are STDs. Women can be infected not only from sexual intercourse, but also from the use of unclean menstrual cloths; insertion of leaves and other materials into the vagina to increase a male partner's pleasure, prevent pregnancy, or induce abortion; unsafe childbirth or abortion techniques; and other harmful practices such as female circumcision.

Most STDs are RTIs although some STDs, such as syphilis, hepatitis B, and AIDS, are also systemic diseases. Many STDs also affect the mouth, rectum, and urinary tract, the latter being part of the reproductive tract in males but not in females.

Female RTIs originate in the lower reproductive tract (external genitals, vagina, and cervix) and, in the absence of early treatment, they can spread to the upper tract (uterus, fallopian tubes, and ovaries). Infections can ascend from the lower to the upper tract spontaneously to cause pelvic inflammatory disease (PID), but the risks of upper tract infection rise dramatically during procedures such as IUD insertion, abortion, and childbirth when instruments are introduced through the cervix.

Women with RTIs may experience considerable emotional distress in addition to having such physical symptoms as vaginal discharge, discomfort during intercourse, and severe abdominal pain. RTIs can also be fatal, especially in developing countries where there are limited resources for early diagnosis and treatment. In women, some RTIs result in life-threatening peritonitis (inflammation of the lining of the abdominal cavity, potentially fatal ectopic pregnancy (gestation in the fallopian tube), cervical cancer, and transmission of the human immunodeficiency virus (HIV), the organism that causes AIDS. Some RTIs cause infertility, resulting from post-infectious blockage of the fallopian tubes, fetal loss (miscarriage or stillbirth), and infant death due to premature birth, Iow birthweight, or congenital infection. Infected children who survive infancy may be permanently disabled or die young.

Infections of the Lower Reproductive Tract

According to the limited data available, lower tract infections are common in most developing countries. Studies of women visiting family planning or obstetric and gynecology clinics, for example, have found evidence of gonorrhea among up to 12 percent of women studied in Asian groups, 18 percent in Latin America, and 40 percent in Africa. Because there have been so few studies of RTIs in developing countries, information on the complications of common infections is scarce. Lack of awareness of RTIs among many health workers and in the general population increases the likelihood that lower tract infections remain untreated, and thus result both in further spread of infection and long-term complications.

Genital Ulcers and Other Lesions

Syphilis is declining in some countries but increasing in others. The primary and most infectious stage consists of painless ulcers that are often unnoticed by women. If untreated, the disease proceeds to a secondary stage of systemic infection, followed by an extended latent phase, and a potentially lethal tertiary stage. In pregnant women, early stages of syphilis can result in intrauterine growth retardation, premature birth, stillbirth and congenital infection of the infant. Studies of prenatal clients in 11 African countries found evidence of infection in 2-33 percent of pregnant women, with a median infection rate of 12 percent. Genital lesions caused by syphilis increase the risk of HIV transmission.

Genital herpes, caused by the herpes simplex virus, produces painful genital ulcers that heal spontaneously but recur, the initial outbreak being longest and most intense. Although there is no medical cure yet, symptoms can usually be controlled with therapy. Herpes is most infectious when sores are open, but the disease can also be spread to sexual partners by individuals who are not aware of any symptoms. Although childbirth during an active outbreak of a mother's primary infection is rare, 20-50 percent of babies born under these circumstances will be infected at sites such as the eyes, skin, mouth, central nervous system, or lungs. The majority of infants with infections extending beyond the skin, eyes, and mouth will suffer permanent neurological damage or death.

Chancroid occurs frequently in developing countries, particularly in Africa. While this disease usually causes a painful ulcer in men, it may occur without symptoms in women. As with other genital lesions, chancroid appears to increase the risk of HIV transmission.

Genital warts are small painless growths caused by the human papillomavirus (HPV), and may be the most common viral STD in industrialized countries. The precise prevalence of HPV infections is unknown, however, because most HPV infections are asymptomatic. These infections are difficult to treat and recurrent infections are common. Preliminary data have established a link between genital warts and HIV infection. Several of the over 50 types of HPV appear to be associated with increased risk of cervical cancer.

Vaginal Infections

Bacterial vaginosis (BV) is probably the most common of all vaginal infections. It can occur without symptoms, or be accompanied by excessive malodorous vaginal discharge. The organisms causing BV are normally found in low numbers in the vagina. BV results from their rapid multiplication due to a variety of factors that upset the normal balance of bacteria in the vagina. BV may cause upper tract infection. In pregnant women, this may lead to the birth of a premature infant; in non pregnant women, infertility or tubal pregnancy may result.

Candidiasis, like BV, results from overgrowth of normal vaginal flora. Symptoms include vaginal discharge, irritation, and vaginal itching, although no long-term or severe complications result. Candidiasis is a common infection, occurring among 11-25 percent of women tested in 17 studies conducted in developing countries. Pregnant women and women taking antibiotics are especially vulnerable.

Trichomoniasis, a very common STD, may be associated with profuse discharge, burning during urination, bad odor or, occasionally, lower abdominal pain. Preliminary studies show an association with increased risk of HIV transmission. The median prevalences of trichomoniasis from studies in Africa, Asia, and Latin America are 19 percent, l1 percent, and 12 percent respectively.

Bacterial vaxinosis, candidiasis and trichomoniasis are all treatable infections.

Cervical Infections

Chlamydia, the most common bacterial STD in some industrialized countries, is particularly difficult to control for three reasons. First, the majority of women with chlamydial cervicitis have no symptoms so they rarely seek care. Second, accurate tests for chlamydia are technically demanding and expensive. Finally, at least a week of therapy is required to eradicate lower tract chlamydial infection, in contrast to the single dose regimens available for many other bacterial STDs.

Chlamydia can lead to extremely serious complications. Infection in the upper tract causes infertility more frequently than does infection caused by gonorrhea. During pregnancy, chlamydia may cause stillbirth, premature birth, and congenital infections such as pneumonia or eye infections. It also appears to be associated with an increased risk of HIV transmission. Unfortunately, very little information is available about the prevalence of chlamydia in developing countries. Five African studies found infections in 4-23 percent of women attending family planning or prenatal clinics, or presenting for delivery.

Gonorrhea is believed to be the most common preventable cause of PID and tubal infertility worldwide. Prevalent in most Western countries, gonorrhea is hyperendemic in parts of central Africa. It is spread easily: a man's risk of acquiring the disease in a single heterosexual encounter with an infected partner is approximately 20-25 percent, while a woman's risk is probably higher because infected secretions from the male are retained in the vagina following intercourse. In women, symptoms of cervical infection can include abnormal vaginal discharge and burning during urination; upper tract infection may be associated with lower abdominal pain and abnormal menstruation; and a blood-borne phase of infection may be manifested by rash and painful joints. Cervical gonorrhea is, however, asymptomatic in at least 20-50 percent of women. Gonorrhea can produce spontaneous abortion, prematurity, and potentially blinding eye infections in newborns. Preliminary data now link gonorrhea with an increased risk of HIV transmission. Although gonorrhea can be treated with antibiotics, all increasing number of strains are resistant to those antibiotic medications most readily available in the developing world.

Cervical cancer, although not an infection, appears to be causally related to lower tract infections from some subtypes of HPV which also cause genital warts. About half a million new cases are diagnosed each year worldwide, more than three-quarters of which are found in developing countries. One study of family planning, obstetrics, and gynecology clients in Addis Ababa, Ethiopia found that cervical cancer was twice as common among women whose first intercourse had occurred before the age of sixteen, as among those whose first intercourse was at age sixteen or older (21 percent of all clients were age twelve or younger at first coitus). In a number of developing countries, particularly in Africa, cervical cancer is the leading cause of death from cancer. It accounts for at Ieast 3-5 percent of all adult female deaths in many areas of the world.

Infections of the Upper Reproductive Tract

Pelvic inflammatory disease (PID) consists of infections of the uterus, fallopian tubes, and ovaries. Although PID can occur without significant pain, symptoms usually include abdominal pain and abnormal vaginal discharge. Acute cases may require hospitalization. The spread to the upper reproductive tract of gonococcal and chlamydial infections and of bacterial vaginosis organisms is often facilitated by IUD insertion, unsafe abortion or childbirth. PID can cause severe inflammation and scarring of the fallopian tubes and ovaries, and damage increases with the severity of inflammation and with each recurrent episode.

Long-term consequences of PID include infertility, potentially fatal tubal pregnancy, chronic pelvic pain, and recurrent bouts of upper tract infection. Upper tract infections during pregnancy raise the possibility that a fetus will abort spontaneously or that an infant will be born too soon and too small. Studies of the prevalence of PID in developing countries are scarce, but rates as high as 20 percent have been found in studies of village women in Kenya, Uganda, and India.

RTIs resulting in blockage of the fallopian tubes are the major, preventable cause of female infertility in developing countries. About 15-25 percent of women who develop PID become permanently infertile because of tubal scarring following infection. Before the advent of antibiotics, infertility rates as high as 60-70 percent were noted following PID. In some African countries in the 1960's and 1970's, from 15-30 percent of married women passed through their reproductive years without hearing children whereas the typical rate of involuntary infertility in populations is about 3-7 percent. Although men may be responsible for up to one-third of all cases of infertility in many developing countries, the blame most often falls on women. A vicious cycle may occur in which STDs introduced by the husband's extramarital contacts result in a wife's post-infectious infertility. He then abandons her, infects other women, and she may turn to prostitution as the only means of supporting herself.

Women's Biological and Social Vulnerability to RTIs

The major causes of RTIs in women are STDs, poor obstetric care, and unsafe abortion. Each of these causes is linked inextricably to women's biological and social roles.

The gender asymmetry of STDs places women in a particularly vulnerable position in disease transmission. Not only is an uninfected woman more likely to acquire an STD from an infected male partner than vice versa, but she is likely to suffer more serious long-term consecuences such as PID, tubal pregnancy, cervical cancer, and infertility. Moreover, her partner's sexual behavior can affect her risk of developing cervical cancer. The association between cervical cancer and a woman's number of sexual partners is well established. Less recognized is the fact that even if a woman is monogamous, her risk of acquiring cervical cancer increases with the number of sexual partners of her husband.

Despite higher levels of male sexual mobility in most societies, as measured by average number of sexual partners, women are often blamed for the spread of STDs. In some languages STDs are even called "the woman's disease." Published research on STDs among heterosexuals often describes female prostitutes as reservoirs of infection while neglecting to recognize the explicitly male demand for services, as well as their refusal to use condoms, and their role in spreading infections to other women.

Understanding the social position of girls and women within societies and population subgroups is crucial to identifying strategies for the effective prevention, diagnosis, and treatment of RTIs. In societies where a belief in male supremacy coexists with restrictive social structures that limit women's economic, social and legal independence, men often maintain strong control over female sexuality. Due to double standards of sexual behavior, sexual coercion, and gender discrimination in schooling, employment, and property and legal rights, girls and women are frequently powerless either to avoid intercourse with an infected man or to insist that he use a condom or remain monogamous. As a village woman in Sri Lanka explains, "What is the good of refusing [a husband's sexual demands], they will never let us alone. [If I refuse] he will go to some other woman and then what will become of me and my children?

It can be very difficult both for women in nonmarital relationships as well as for married women to ask a man to be tested for an STD, to seek treatment, or even to use a condom, especially where the use of condoms connotes prostitution. Fears of social consequences often take priority over fears of health consequences, making infected women reluctant to inform their male partners of their diagnosis, and non-infected women reluctant to inquire about the health status or other sexual involvements of the men they are with. For many women, the perceived risk of being beaten, divorced or abandoned, or of losing a source of emotional or financial support, far exceeds the perceived health risk of acquiring an STD.

In many cultures women accept vaginal discharges, discomfort during intercourse, or even the chronic abdominal pain which accompanies some RTls as an inevitable part of their womanhood. RTls are something to be endured, along with other reproductive health problems such as sexual abuse, menstrual difficulties, contraceptive side effects, miscarriages, stillbirths, and potentially life threatening clandestine abortion or childbirth.

RTls have an additional element of shame and humiliation for many women because they are considered unclean, whereas for young men the symptoms of RTls are sometimes taken as a sign of sexual potency.'~ The invisibility and taboos surrounding RTls, and the belief that they should be endured, create a culture of silence within families and communities that can severely compromise women's health.