SEXUALLY TRANSMITTED DISEASES docx

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A sexually transmitted disease (STD) is any infection acquired pri￾marily through sexual contact. STD is a general term, and the

causative organisms, which are harbored in the blood or body se￾cretions, include viruses, mycoplasmas, bacteria, fungi, spirochetes,

and minute parasites (e.g., crab lice, scabies). Some of the organ￾isms involved are found exclusively in the genital (reproductive)

tract, but others exist simultaneously in other systems. Additionally,

various STDs often coexist, and when one is found, others should

be suspected. There is a range of intimate bodily contact that may

transmit STDs, including kissing, sexual intercourse, anal inter￾course, cunnilingus, anilingus, fellatio, and mouth or genital to

breast contact. Physicians are required to report most STDs to lo￾cal public health departments.

The vast majority of female genital tract infections are acquired

sexually. Female genital tract infections are divided into lower geni￾tal tract and upper genital tract (or pelvic) infections. The lower gen￾ital tract infections (including a number of STDs and their sequelae)

are discussed in Chapters 20 and 21, and they include viral infections

(herpes simplex, human papillomavirus, and molluscum contagio￾sum) and vulvar infestations (pedicularis pubis and scabies). Com￾mon types of vulvovaginitis (e.g., Trichomonas, bacterial vaginosis,

and Candida) and some of the sequelae of STDs (e.g., infections of

Bartholin glands and cervicitis) also are discussed in Chapter 20. This

chapter deals with upper genital tract infections, the most serious,

most directly sexually transmitted diseases and their sequelae.

HUMAN IMMUNODEFICIENCY

VIRUS (HIV) INFECTIONS

The human immunodeficiency virus (HIV) was first reported to

cause disease in 1981. In the United States, AIDS is now the fifth

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SEXUALLY TRANSMITTED

DISEASES

CHAPTER

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BENSON & PERNOLL’S

682 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

leading cause of death among women of childbearing age. More￾over, it is the leading cause of death in this age group in New

York City. This is now a worldwide crisis, with millions affected,

especially in developing countries. One of the problems in recog￾nition of HIV infection is a long, asymptomatic latency of

2 months to 5 years. The mean age at diagnosis of HIV infection

is 35 years.

The virus is present in blood and all body fluids and is trans￾mitted by sexual contact (.70%), by parenteral exposure to infected

blood or body fluids, or by transplacental passage of the virus from

mother to fetus. The highest-risk groups for HIV infection are ho￾mosexuals, bisexual men, intravenous drug abusers, and hemo￾philiacs receiving blood transfusions. Others at high risk are pros￾titutes and heterosexual partners of men in the high-risk groups. All

blood must be screened for HIV before transfusion to minimize

transfusion risk. Women acquire the virus more easily from men

rather than the reverse because the concentration of HIV in semen

is high and mucosal breaks at the introitus or vagina with inter￾course occur more commonly than do breaks in penile skin.

Although anti-HIV antibodies develop within 12 weeks of ex￾posure, 45%–90% of persons infected with HIV will develop symp￾toms of an acute infection similar to mononucleosis within a few

months. They experience weight loss, fever, night sweats, pharyn￾gitis, lymphadenopathy, and an erythematous maculopapular rash.

Most of these symptoms resolve within a few weeks, although the

patients remain infectious despite being asymptomatic. Some will

progress to develop symptoms of AIDS-related complex (ARC),

with early immunosuppression (decreased CD4 lymphocytes).

ARC is usually marked by generalized lymphadenopathy, weight

loss, diarrhea, malabsorption, and wasting. Some patients experi￾ence further immunosuppression and develop AIDS (any of the

symptoms of acute sepsis, opportunistic infections, Kaposi’s sar￾coma, cognitive difficulties, or depression). Once AIDS has been

diagnosed, mortality is
90%. Immunologic abnormalities associ￾ated with AIDS include (but are not limited to) lymphopenia, de￾creased T helper cells, decreased T lymphocytes, hypergamma￾globulinemia, and an inverted T4/T8 ratio.

Because there is no cure for HIV, current therapy only slows the

progression of the disease. Hence, there is every reason to stress

prevention. Other than abstinence or having a monogamous rela￾tionship with a known noninfected partner, using latex condoms lu￾bricated with nonoxynol 9 is the most effective method of limiting

the risk of infection. If a woman is HIV positive, she should be

counseled (1) not to donate blood, plasma, tissue, or organs; (2) to

avoid pregnancy; (3) to maintain a monogamous relationship;