10 Women’s Health

STUDENT LEARNING OUTCOMES

At the end of this chapter you should be able to:

• Discuss the challenges that still lie ahead for women in medicine
• Recall the areas of inequity in medicine between male and female physicians
• Identify gender and racial gaps that still exist in healthcare
• Analyze the ways women are different than men when it comes to health
• Evaluate the impact of criminalizing abortion on women’s healthcare
• Describe the pelvic exam and explain its usefulness
• Explain the different types of reproductive tract infections
• Recall the methods used to treat the different RTIs

A perspective on women’s healthcare

Known as the “field of health and healing” (Medical News Today, 2018) medicine is essential to individual and public well-being and has far-reaching social, economic, and global implications. From the beginning of the modern era onward, inequity in medicine has been the rule rather than the exception. “Historically, most medical research was conducted in men and the findings from such studies were assumed to be equally applicable to women. Sex differences and gender disparities in health and disease have therefore long been unknown and/or ignored” (Peters et al. 2016). The first bona fide female physician (with a medical degree from a U.S. medical school) was Elizabeth Blackwell, pictured on the ight. She graduated first in her class yet was unable to practice medicine in the same manner as her male counterparts.

Born in England in 1821 and later emigrating to Ohio, Elizabeth Blackwell states in her diary (1914) that she was inspired to become a physician by a friend suffering from a chronic illness who had encouraged her by saying “why not study medicine? If I could have been treated by a lady doctor, my worst sufferings would have been spared me”. Medical school seemed an impossible goal but Blackwell was steadfast, she wrote in her journal that “a force stronger than myself then and afterward seemed to lead me on; a purpose was before me which I must inevitably seek to accomplish”. While working as a teacher in Charleston, SC, Blackwell was able to gain access to the medical library of her employer Dr. Dickson, and applied to numerous medical schools facing rejection each time- with one reply being very clear: ‘you cannot expect us to furnish you with a stick to break our heads with’. However some were sympathetic to her desire to learn and at one point she was advised by Dr. Pankhurst, the Professor of Surgery at the medical school in Philadelphia to sneak into his lecture by dressing in “masculine attire…to watch the class”. Feeling as though this was a question of justice she did not give up her endeavor to be admitted and was finally accepted to the Geneva College in rural New York. Although she encountered discrimination, Blackwell excelled and graduated first in her class in 1849. After gaining practical experience in London and Paris, she returned to Philadelphia. Unable to gain much experience with patients in established hospitals due to misogyny Blackwell opened a small clinic to treat poor women with her sister Dr. Emily Blackwell (who had followed Elizabeth’s path, becoming the second woman to earn a medical degree in the U.S. at Case Western) and colleague Dr. Marie Zakrzewska (fellow class member of Emily at Case Western). Zakrzewska went on to establish the New England Hospital for Women and Children in Boston which became a primary training hospital for several generations of women physicians. Blackwell eventually returned to England where in 1875, she became a professor of gynecology at the new London School of Medicine for Women.

Gender imbalance in medical specialty

Dr. Blackwell was able to show that women could handle the rigor of medical school and served as an inspiration to other women. She also campaigned for better preventative care for women. Many women have followed in Blackwell’s footsteps, yet women still do not have equal representation in medicine. According to the recent AAMC report (AAMC 2022), only 37% of active physicians in the U.S. are women. At leadership levels, the difference is even more stark. A 2016 study by Hofler et al. (2016) examined 950 medical school departments including the following specialties: Anesthesiology, Diagnostic Radiology, General Surgery, Internal Medicine, Neurology, Obstetrics and Gynecology, Pathology, Pediatrics, and Psychiatry found that among “all nine specialties…women comprised 13.9% of department chairs, 22.6% of vice chairs, 21.6% of division directors”. The discrepancies in certain fields directly impact women’s health. For instance “although cardiovascular disease is the leading cause of death among women, just 14% of cardiologists are women” (Commonwealth Fund 2023). Physicians have often failed to recognize unique aspects of heart disease in women and this has “contributed to less aggressive lifestyle and medical preventive interventions in women relative to men” (Garcia et al. 2016), and “cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated” (Vogel et al. 2021).

Discrimination and dismissiveness persist in healthcare

Over the last 200 years, medical advancements and technological innovations have drastically improved outcomes for women. Yet the differential treatment of patients based on gender, racial, and socioeconomic status persists and contributes to disparities in healthcare. Like all professions, healthcare providers exhibit implicit bias, the degree of which varies by physician race (white physicians exhibit a pro-white bias) and gender, (women show less implicit race bias than men) (Sabin et al. 2009; Sabin 2022). This bias directly leads to disparities in care (Chapman, Kaatz, and Carnes 2013). Findings from a recent survey document women having negative experiences with their healthcare provider, with nearly 30% saying physicians repeatedly dismissed their concerns and 10% reporting discrimination (Long et al. 2023).

The most common reason for a woman to be admitted to a hospital is for childbirth however maternity services in hospitals have been characterized as “disrespectful” for women and their families (WHO, 2014). Although biomedical prenatal care may reduce infant and maternal mortality rates, the intense medicalization of pregnancy can make women feel as though they are “secondary elements in the birth scenario”, subject to being controlled instead of having a needed sense of agency over their bodies (Jardim and Modena 2018). The term “obstetrics violence” recognized by the World Health Organization refers to trauma women experience during delivery and birth involving mistreatment, disrespect, abuse, negligence, and violation of human rights by health professionals. Obstetrics violence occurs both nationally and globally (Diaz-Tello 2016).

Barriers to quality healthcare

Women of color experience the poorest health outcomes of any group in the United States with shorter life expectancies, higher rates of chronic conditions, and significantly higher rates of maternal mortality (Commonwealth Fund Report, 2023). Historical policies of racial discrimination have significantly impacted BIPOC women. Iyer et al. (2022) found a strong correlation between socioeconomic and environmental factors that explain racial disparities in mortality. Chinn, Martin, and Redmond (2021) point out how the historical “treatment by the US medical establishment, particularly in gynecology, contributes to the present-day health disadvantages of Black women.” Compounding this issue is the fact that there are still few physicians of color. As of 2018, only 5.8% identified as Hispanic, and 5.0% identified as Black or African American compared to 56% who identified as White (AAMC 2019). Making matters worse, on June 29, 2023, the US Supreme Court ruled in the case Students for Fair Admissions Inc. v the University of North Carolina (and the paired case against Harvard) overturning the use of affirmative action in higher education. Universities will no longer be able to consider race and ethnicity for admissions and this has the potential to significantly reduce the number of physicians of black and other minority races. The ruling will likely “increase the health inequity in underserved communities” (Montgomery Rice, Elks, and Howse 2023).

Another marginalized group in terms of healthcare is those identifying as transgender and gender-nonconforming. They often avoid seeing a doctor altogether because the experience causes so much stress. Tabaac et al. (2018) report that discriminatory attitudes and lack of knowledge create barriers to healthcare for transgender people.

Women’s health has been a national priority but requires continued financial, political, and cultural support. The U.S. Department of Health and Human Services (HHS) Office on Women’s Health (OWH) was established in 1991 “to improve the health of U.S. women by advancing and coordinating a comprehensive women’s health agenda” (“Office of Women’s Health” 2023). Since that time the OWH has helped to improve the following for women: access to health care, improved screening techniques, executed key policy changes, approved lifesaving vaccines, and issued landmark reports (Woods et al. 2015). Yet, more still needs to be done.

There are real health differences between men and women

First and foremost it is important to recognize women and men are different. Specific biological differences impact disease etiology (causes of disease) and differences in adverse drug responses. Underlying sex differences impact disease susceptibility, symptoms and progression. However, the medical community has only recently recognized that examining both sexes in both basic and clinical research is essential (Golden et al., 2017). To date, numerous health-related differences in women have been noted.

In 2001, the National Institutes of Health (NIH), the world’s premier medical research organization, created a mandate requiring the inclusion of women and minorities in federally funded clinical research in “sufficient [numbers] to provide for a valid analysis of any differences … in response to drugs, therapies, and treatments.” This mandate was amended in 2017 to include the requirement that recipients conducting applicable NIH-defined Phase III clinical trials ensure results of valid analyses by sex or gender, race, and/or ethnicity are submitted to ClinicalTrials.gov so that unpublished information that could reveal sex or gender/race differences will not be lost to the scientific community (NIH website). However, Nazha et al. (2019) found that both women and ethnic minority individuals in cancer treatment clinical trials are still significantly underrepresented.

Reproductive healthcare by women has recently been limited

Women’s healthcare has suffered as a result of the July 2022 Supreme Court decision on Dobbs v. Jackson Women’s Health Organization that overturned Roe v. Wade, (the 1973 landmark decision that decriminalized abortion in the United States). It has led to the passage of state laws that “criminalize physicians for medical care nationally recognized as the standard of care” (Binnall 2023). Moreover, global data indicates that these laws will not necessarily stop women from seeking abortions but will certainly make them less safe (Sidik 2022). As of the 2020 census over 30 million women are living in the states where it is now illegal or effectively impossible* to access abortion, (Alabama, Arkansas, Idaho, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, West Virginia, Utah* and Wisconsin*). Recent MacArthur Fellow, Diana Green Foster, along with colleagues, has conducted research showing that “women denied an abortion were more likely than were women who received an abortion to experience economic hardship and insecurity lasting years (Foster et al. 2022). Those seeking assistance living in these states must travel great distances, some over 100 miles, and several states are even attempting to outlaw this travel, i.e. Idaho which recently passed House Bill 242 that forbids adults from “recruiting, harboring, or transporting” a minor seeking abortion care without parental consent. It includes obtaining abortion medication for minors” (Ehardt 2023). It is also important to remember that many women are unable to afford the travel costs now associated with accessing an abortion, not to mention the disproportionate and unequal impact abortion restrictions have on people of color, people with low incomes, LGBT individuals, and those with disabilities (Hyatt, McCoyd, and Diaz 2022).

The overturning of Roe v. Wade also has major ramifications for the quality of care that future healthcare providers can give to women patients. In many medical schools graduates will not be effectively trained in how to deal with “pregnancy complications including placental abruption, infection, ectopic pregnancy, and eclampsia because the same medications and surgical techniques utilized for abortion also treat obstetric complications” (Berg and Woods 2023). The impact from the decision is already being felt in emergency rooms in states criminalizing abortion after 6 weeks creating “clinician fear of legal ramifications when managing ectopic pregnancies” as well as hampering their ability to freely prescribe emergency contraception to survivors of sexual assault (Samuels-Kalow et al. 2022). An article published in The Guardian (McLaughlin 2023) reports that “in Idaho, doctors are leaving, looking for states where politics don’t dictate how they practice medicine”… the “local hospital, announced that it would no longer provide any obstetrical care”. Research shows an inverse relationship between abortion restrictions and maternal outcomes with states that restrict abortion having higher maternal mortality than states that either protect or are neutral towards abortion (Addante et al. 2021). It is important to look at the data and make informed decisions regarding how this ruling is harming women. A woman’s access to the best possible healthcare depends upon the removal of structural barriers and the protection of both her and her physician’s rights.

Female-specific infections

Reproductive tract infections

Reproductive tract infections (RTIs) are a serious issue for women that includes both non-sexually transmitted infections (non-STIs) and sexually transmitted infections (STIs) of the reproductive tract. The best way to deal with STIs is by practicing safer sex. This includes discussing past partners, history of STIs and drug use with potential partners before beginning sexual relations; using latex condoms every time (even during oral sex); and avoiding drinking alcohol or using drugs to lower the risk of participating in high-risk sex. Gynecology is the branch of physiology and medicine that deals with the functions and diseases specific to women and girls, especially those affecting the reproductive tract. Often gynecology is combined with obstetrics (a branch of medicine and surgery concerned with childbirth and the care of women giving birth). Women are encouraged to visit a gynecologist annually as part of a routine check-up and as a way to discuss day-to-day health concerns to make sure everything in their mind-body is working well together. Preventive health care is essential to minimize disease and other health problems, or screen for disease at an early stage when treatment is likely to work best.

What to expect during the annual visit (American College of Obstetricians and Gynecologists, 2023):

• talk about specific health concerns or questions
• talk about pregnancy planning or birth control
• talk about menopause and healthy aging
• pelvic exam for cervical cancer screening and a breast exam, depending on the patient’s age

The pelvic exam

The pelvic exam is an uncomfortable experience and women often report being anxious and fearful beforehand, yet it is an effective way to screen for cervical cancer and sexually transmitted infections. Callahan, Caughey, and Heffner (2004) describe how the pelvic exam is performed: lying down on the examination table with knees at a 90-degree angle and the feet in stirrups (lithotomy position), the clinician examines the vulva.

A speculum, a metal instrument that is used to widen the vagina for proper viewing and access to the cervix, is inserted and a sample from the cervix is taken by scraping the outer cervical cells (exocervix) with a scapula followed by a brush inserted into the cervical os to collect inner-cervical (endocervix) cells (see image on the left). The sample is then used to conduct a Pap test which checks for abnormal cells (cervical cytology screen). Cervical cancer is caused by several strains of the Human papillomavirus (HPV), discussed below, which can be detected using PCR. The following current Pap screen guidelines are from the American Cancer Society: first Pap test at age 21, followed by Pap testing every 3 years from age 25 – 65 they recommend an HPV test every 5 years.

In the past a bimanual exam (the clinician inserts gloved fingers of one hand into the vagina while pressing down on the abdomen with the other hand) was routinely conducted to feel for potential tumors however this is ineffective in screening for ovarian cancer or acute abdominal pain or vaginal bleeding, instead an ultrasound is much more effective (Qaseem et al. 2014).

Vulvovaginal candidiasis (VVC)

Vulvitis is an irritation and inflammation of the vulvar region. It may be accompanied by itching referred to as pruritis. There are numerous causes of vulvitis but the most common one is vulvovaginal candidiasis also known as a yeast infection, a non-STI. The fungus Candida albicans is part of the normal mucosal vaginal flora. However Lactobacillus bacterial species are considered the most common microbes found in healthy individuals, and they play an important role in keeping C. albicans in check (Petrova et al. 2017). Sometimes the balance is disrupted in the vaginal ecosystem causing C. albicans to overgrow resulting in infection. This may be due to hormonal shifts, antibiotics, or changes in the immune system and increased incidences have been noted in pregnant and premenopausal women.

The following information about the symptoms, diagnosis, and treatment of VVC is from Sobel et al. (1998). The symptoms of VVC are pruritus, soreness, a whitish discharge, painful urination, and dyspareunia (painful sex). Self-diagnosis is unreliable, the infection can be confirmed by the collection of a vaginal swab during a pelvic exam, the sample is viewed under a microscope followed by confirmation from vaginal culture for C. albicans. Over-the-counter antifungal treatment works well for uncomplicated cases. Recurrent VVC is defined as four or more episodes of proven infection during 12 months treated with judicious use of antimycotic therapy.

Bacterial vaginosis (BV)

BV affects nearly one-third of all women and is even more prevalent in Black women, it occurs when there is a shift in the predominant bacterial species in the vagina. The most common organism involved in BV is Gardnerella vaginalis, although the presence of G. vaginalis in the vagina does not always result in BV. It is often asymptomatic however BV increases the risk of some of the STIs, such as herpes simplex virus type 2 (HSV-2), HPV, HIV, and chlamydial, gonococcal, trichomonal infection, and BV is considered a risk factor for pelvic inflammatory disease (PID) (Chen et al. 2021).

BV is often asymptomatic however one may notice an increased vaginal discharge that has a fishy odor. BV can be diagnosed by the collection of a vaginal swab during a pelvic exam used in two different tests, the Amsel criteria and Nugent score (Colonna and Steelman 2023). The Amsel criteria involve four criteria (3 out of 4 present = confirmed BV) used to determine the presence or absence of BV which are:

1. thin, white, yellow, homogeneous discharge
2. clue cells on wet mount microscopy
3. a vaginal fluid pH of over 4.5 when placing the discharge on litmus paper
4. fishy odor released after adding 10% potassium hydroxide (KOH) solution to wet mount – also known as “whiff test”

The Nuget score test is the examination of the smear under a microscope for three bacteria morphotypes: Lactobacillus, Gardnerella, and curved gram rods. Each of these three categories receives a score based on the number of bacteria counted.

BV is treated using antibiotic oral metronidazole (500 mg twice a day for 7 days), or intravaginal metronidazole gel (5 g once a day for 5 days), or intravaginal clindamycin cream (5 g once a day for 7 days) (CDC guidelines for BV treatment).

Trichomonas vaginalis (TV)

Trichomonas vaginalis is the most common non-viral STI infectious disease. It is caused by a protozoan that infects the vulva, vagina, and urethra, and approximately 2% of all women in the United States are infected (Sutton et al. 2007). However Black women are significantly more impacted than other racial groups. Meites et al. (2015) report that “particularly high prevalences have been detected among incarcerated individuals, at 9%–32% among incarcerated women.” TV is associated with infertility, the facilitation of HIV transmission, and preterm birth or low birth weight delivery (Muzny 2018).

Women are often asymptomatic but symptoms include profuse odorous vaginal discharge, and may also be accompanied by vulvar erythema (abnormal redness) and pruritus. Diagnosis is made from a wet prep of a vaginal swab and identification of the protozoan under the microscope where active movement of the flagella can be observed. However, according to the CDC, nucleic acid amplification tests (NAATs) are highly sensitive, detecting more T. vaginalis infections than wet-mount microscopy. Treatment involves a single high dose of oral metronidazole or a week-long course of 500 mg twice a day.

Chlamydia trachomatis

Chlamydia species are bacteria but like viruses are also obligate, intracellular pathogens. C. trachomatis is an STI and is the main cause of pelvic inflammatory disease (PID) in women. “Untreated chlamydial infection leads to PID in 20–40% of infected women” and PID is a major cause of infertility (Manavi 2006). An infected mother can infect her baby during vaginal delivery. Approximately 75% of incident infections in women are asymptomatic therefore it is difficult to determine the prevalence, however, it is estimated that 1 in 20 sexually active young women aged 14-24 years has chlamydia (Torrone, Papp, and Weinstock 2014). Like all STIs the risk of infection increases with unprotected sex (sex without a condom) and having multiple partners. Since the majority of women infected with C. trachomatis are asymptomatic, many remain undiagnosed.

Diagnosis of chlamydia is done by a clinician swabbing the vagina and diagnosis is based on NAATs which detect C. trachomatis DNA. Treatment involves a single high dose of oral metronidazole or a week-long course of 500 mg twice a day.

Neisseria gonorrhoeae

Gonorrhea is caused by the sexually transmitted obligate bacterium Neisseria gonorrhoeae. It is of increased concern because the pathogen “has shown an extraordinary ability to develop resistance to all antimicrobials introduced for its treatment” (Suay-García and Pérez-Gracia 2018). The incidence of gonorrhea in women in the United States has increased over the years (Learner et al. 2020). The increasing rate of infection in women is “associated with a marked increase in infections associated with injection drug use, methamphetamine use, heroin use and in sex with a person who injects drugs” (Bamberger 2020). Similar to chlamydia, most N. gonorrhoeae infections are asymptomatic in women. One reason for this is due to the site of infection which is predominantly the epithelial cells of the ectocervix (Yu et al. 2019). Left untreated infection may lead to PID and infertility among women. According to Meyer and Buder (2020), it can be diagnosed using microscopy, culture, or NAATs. Microscopy involves swabbing a sample from the cervix and then using Gram´s staining, N. gonorrhoeae shows as Gram-negative diplococci. Culture is used to confirm biochemical and immunological testing and to determine antibiotic resistance. NAATs are the most sensitive techniques to detect N. gonorrhoeae however it is the most costly. The recommended treatment from the CDC as of 2022 is a single dose of 500 mg of intramuscular ceftriaxone.

Urinary tract infections (UTIs)

Urinary tract infections are the most common bacterial infections in women, especially those who are sexually active, pregnant, and post-menopausal. Post-menopausal women have higher rates of UTIs because estrogen deficiency plays an important role in the increase in uropathogenic Escherichia coli bacteria in the urine (Raz 2011; Wang et al. 2013). Typically bacteria enter through the urethra and then travel to the bladder and kidneys. As stated by Sheerin (2011) “infection of the bladder causing cystitis (inflammation) is the most common UTI” and “acute uncomplicated cystitis is the commonest form of symptomatic UTI, affecting 15% of women each year and, cumulatively, 40% of women at some point in their life (30% of these have recurrent infections).”

Women commonly present with symptoms of discomfort or pain at the urethral meatus or a burning sensation throughout the urethra, along with cystitis and or frequent urination, and incontinence. If left untreated a UTI can infect the kidneys resulting in severe damage and life-threatening sepsis (an extreme reaction by the body to infection), but most infections are less severe.

UTI diagnosis involves urinalysis and urine culture. Bates (2013) reports that the “most obvious indicator of bacterial infection in the urine is the presence of bacteria…pyuria, which is defined as urine WBC >10 or positive leukocyte esterase, indicates the presence of inflammation”. Women with recurrent UTIs can correctly self-diagnose 84% of the time (Chu and Lowder 2018). Treatment of UTIs involves a course of antibiotics. The most common pathogens associated with UTIs are Escherichia coli, followed by Proteus mirabilis, Klebsiella pneumoniae, and Staphylococcus saprophyticus and it is best to match the proper antibiotic with the infecting pathogen (Bates, 2013).

Viral Infections

Viruses are distinct from microorganisms because they are acellular (not cells) and obligate intracellular parasites (they require a host for reproduction). Additionally, most viruses are very small, generally composed of nothing more than nucleic acid surrounded by a capsid composed of proteins. Viruses are extremely diverse and have greatly influenced the evolution of cellular life (Forterre and Prangishvili 2009). New viruses, like Sars-Cov2, are constantly emerging while older ones evolve and challenge the latest advancements in treatment making them particularly difficult to combat. Those that infect the female reproductive tract discussed below are sexually transmitted therefore the best way to deal with viral STIs (like all STIs) is prevention through safer sex practices.

Humanpapilloma Virus (HPV)

HPV is sexually transmitted, spread by skin-to-skin contact, and is considered the most common viral sexually transmitted infection worldwide. HPV is highly contagious, “sexual contact with an HPV-infected individual results in a 75-percent chance of contracting the virus” (Yanofsky, Patel, and Goldenberg 2012). HPV disproportionally affects women because the cervical cells are highly susceptible to HPV infection. The virus invades cutaneous and mucosal epithelium which can be infected anywhere along the genital tract, including the vulva, vagina, cervix, and perianal regions (Yanofsky, Patel, and Goldenberg 2012). Because HPV “disrupts the mucosal integrity and immunity” HPV infection is also associated with an increase in HIV transmission (Dreyer 2018). There are over 200 types of HPV, a fraction of which are directly responsible for cervical cancer in women known as the high-risk types. They are also responsible for anal and oropharyngeal cancers, totaling 5% of cancers worldwide. The high-risk types include types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59, whereas low-risk types 6 and 11 are responsible for benign genital warts (de Sanjosé, Brotons, and Pavón 2018). A discussion of how HPV causes cervical cancer is found in the following Women-Specific Cancer chapter.

Symptoms and treatment of HPV

The clinical symptoms and treatments are reviewed by Yanofsky et al., (2013). Often HPV is asymptomatic, however, some types (particularly 6 and 11) do cause genital warts also known as condylomata acuminata (CA) that can be found in large clusters and may cause discomfort, burning, and pruritis. Genital warts vary in appearance and may be flat, dome-shaped, cauliflower-shaped, or pedunculated. Once infected with HPV, the virus typically requires an incubation period ranging anywhere from three weeks to eight months before any symptoms present. Studies tracking women over time have shown that within six months nearly half of all HPV infections clear up and that the great majority (>90%) clear within a few years after infection (de Sanjosé et al., 2018).

There are a variety of treatments used to remove genital warts including creams that can be administered at home (podophyllotoxin, imiquimod, and sinecatechins) or those administered by a clinician such as trichloroacetic acid (TCA) 80–90% solution. Additionally, clinicians can administer cryotherapy electrosurgery, surgical scissor excision, and laser therapy to remove warts.

The HPV vaccine

Four vaccines have been developed to prevent HPV infection, the quadrivalent (4vHPV) Gardasil, bivalent (2vHPV) Cervarix, 9-valent (9vHPV) Gardasil-9 and the bivalent Cecolin in China (Ebrahimi et al., 2023). The vaccine Gardasil 9 (Merk) protects against HPV types 6, 11, 16, and 18. Note that this includes the two most prevalent high-risk types that cause cancer and the two most prevalent types that cause genital warts.

The CDC HPV vaccine guidelines are as follows: all children ages 11–12 years get two doses of HPV vaccine, given 6 to 12 months apart. HPV vaccines can be given starting at age 9. Some adults aged 27 through 45 years who were not already vaccinated might choose to get HPV vaccine after speaking with their doctor about their risk for new HPV infections and the possible benefits of vaccination. The FDA first approved the vaccine in 2006 and since that time it has already significantly reduced the burden of disease by preventing viral infection and transmission (Kechagias et al. 2022). However, because of costs and the lack of screening in low and middle-income countries, HPV continues to be a problem (Ebrahimi et al. 2023).

Herpes

Herpes simplex virus type 2 (HSV-2) is a sexually transmitted virus that is responsible for genital ulcers (HSV-1 causes oral infections). “HSV infection is acquired through close contact with an infected person who is shedding virus from their skin or genital secretions” (Gupta, Warren, and Wald 2007). Upon primary infection, the virus becomes latent in neural sacral ganglia therefore HSV-2 infections are lifelong with intermittent viral reactivation and shedding of viral particles from mucosal surfaces (Margolis et al. 2007; Gianella et al. 2015). Genital ulcers can be painful and cause psychological distress and like HPV the mucosal damage caused significantly increases the risk of HIV infection (Gianella et al., 2015). Pregnant women can also transmit HSV-2 to the baby at delivery which can result in central nervous system complications or death of the infant (Gupta, Warren, and Wald 2007).

Treatment of Herpes

HSV-2 cannot be cured but it can be somewhat controlled with anit-viral medication. Current antivirals such as acyclovir and famciclovir are guanosine analogs that disrupt viral DNA replication and are “effective at reducing the time to healing of recurrent and primary episodes” (Birkmann and Zimmermann 2016)

Human Immunodeficiency Virus (HIV)

HIV is sexually transmitted through genital and rectal mucosa. Left untreated, HIV causes a progressive decline in the immune system by destroying immune cells resulting in AIDS (autoimmune deficiency syndrome) the deadly disease first diagnosed in 1981. HIV is a rapidly evolving RNA virus that specifically binds the CD4 receptors on T immune cells. During vaginal intercourse, women are twice as likely to contract HIV infection from men as men are from women, and globally the vast majority of new HIV cases are due to transmission from men to women (Wira and Fahey 2008). It is thought that “intercourse-induced mechanical microabrasions of the mucosal surfaces allow HIV to directly access” immune cells (Hladik and Hope 2009).

Mother-to-infant transmission of HIV occurs at rates of 14% to 42% in various settings (Kourtis et al. 2001). According to the CDC, the incidence of HIV in the United States has declined six percent from 2015 to 2019, however, marked racial disparities exist. Only 13% of the US population identifies as Black, yet nearly 55% of all new HIV infections were reported in Black women. Disparities persist on the global level as well with half of all HIV-positive women living in eastern and southern Africa (WHO, 2023).

Treatment of HIV

No cure or vaccine has yet to be discovered for HIV and over 20 million girls and women are living with HIV (UNAIDS, 2022). Thanks to the development of multiple drugs, HIV is changing from a life-threatening infection to a long-term, manageable condition (WHO, 2023). Combination antiretroviral treatment also known as highly active antiretroviral therapy (HAART) is used to reduce viral loads to undetectable levels. This has also been an effective way to prevent pregnant women from infecting infants at birth (Bailey et al. 2018). The key to HAART is that multiple drugs are simultaneously used each with different mechanisms that block viral replication. This is done to thwart the virus’ ability to evolve resistance (Shafer and Vuitton 1999). Yet the costs for HAART are very high and out-of-pocket expenditure requirements constitute a barrier for some (Assebe et al. 2020).

Prevention of HIV

There is no cure for HIV and although there have been several attempts, a successful vaccine has yet to be developed. Therefore prevention is the best option and several studies demonstrate “correct and consistent condom use can reduce HIV transmission risk by 80%” (Gursahaney et al. 2019). For individuals with a substantial risk of HIV acquisition, such as women living in a high prevalence population, or those who have intercourse without a condom, Pre-exposure prophylaxis (PrEP) is available. PrEP is the daily use of preventive antiretroviral agents by HIV-negative individuals, although “lower efficacy in risk reduction has been observed for vaginal intercourse” (Spinner et al. 2016).

Overall, reproductive tract infections are common and can be caused either by the overgrowth of microbial flora or sexual transmission of infection. They can cause discomfort, infertility, and death. The prevalence of infection varies across populations but with increased awareness and better access/use of condoms for protection against STIs rates can continue to decline. Prevention is key.

Key Terms

Bacterial vaginosis

Candida albicans

Chlamydia

Condylomata acuminata

Dyspareunia

Endocervix

Exocervix

HAART

Herpes

Human immunodeficiency virus

Human papilloma virus

Lactobacillus

Lithotomy position

Neisseria gonorrhoeae

Pap test

PrEP

pruritis

RTI

STI

Trichomonas vaginalis

UTI

Vulvitis

References

AAMC. 2019. “Diversity in Medicine: Facts and Figures 2019.” https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018.

———. 2022. “Physician Specialty Data Report.” Data & Reports. https://www.aamc.org/data-reports/workforce/report/physician-specialty-data-report.

Addante, A. N., D. L. Eisenberg, M. C. Valentine, J. Leonard, K. E. J. Maddox, and M. H. Hoofnagle. 2021. “The Association between State-Level Abortion Restrictions and Maternal Mortality in the United States, 1995-2017.” Contraception 104 (5): 496–501. https://doi.org/10.1016/j.contraception.2021.03.018.

Bailey, H., R. Zash, V. Rasi, and C. Thorne. 2018. “HIV Treatment in Pregnancy.” The Lancet 5 (8): e457–67.

Barker, K.K. 1998. “A Ship upon a Stormy Sea: The Medicalization of Pregnancy.” Social Science & Medicine 47 (8): 1067–76. https://doi.org/10.1016/S0277-9536(98)00155-5.

Bates, B. 2013. “Interpretation of Urinalysis and Urine Culture for UTI Treatment.” US Pharmacy 38 (11).

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Suggested Reading

“The Gynecological Sourcebook” by M. Sara Rosenthal – This resource covers a wide range of women’s health issues, including gynecological cancers. It provides information on prevention, early detection, treatment, and support.

“The Gynecologist’s Second Opinion: The Questions and Answers You Need to Take Charge of Your Health” by William H. Parker, M.D., and Rachel L. Parker – Dr. William Parker addresses common gynecological concerns and provides valuable insights for women seeking a second opinion on their health issues.

“Reproductive Tract Infections: Global Impact and Priorities for Women’s Reproductive Health” by Judith N. Wasserheit and King K. Holmes – This book provides a comprehensive overview of reproductive tract infections, their global impact, and strategies for prevention and management.

“Infections of the Female Genital Tract” by Richard L. Sweet and Ronald S. Gibbs – A textbook that covers a wide range of reproductive tract infections, including bacterial, viral, fungal, and parasitic infections, with a focus on clinical aspects and management.

“Reproductive Tract Infections and Other Gynecological Disorders: A Multidisciplinary Research Approach” edited by Shireen Jejeebhoy, Michael Koenig, Christopher Elias – This book presents a collection of research articles and studies exploring reproductive tract infections and related gynecological disorders from a multidisciplinary perspective.

“The Naked Truth” by Marvelyn Brown and Courtney E. Martin – The surprisingly hopeful story of how a straight, nonpromiscuous, everyday girl contracted HIV and how she manages to stay upbeat, inspired, and more positive about life than ever before.

“Women’s Gynecologic Health” by Kerri Durnell Schuiling and Frances E. Likis – This comprehensive textbook covers a wide range of topics related to women’s reproductive health, including the anatomy, physiology, and common conditions of the female reproductive tract.

Interesting Podcast

The Doctor’s Art Fighting for Empowerment and Equity (with Dr. Pamela Kunz)