In women, chlamydial infections may cause pelvic inflammatory disease, tubal infertility, chronic pelvic pain, and ectopic pregnancy. Chlamydial infection may also be linked to cervical cancer (Koskela et al., 2000). Chlamydial and gonococcal infections may increase susceptibility to and transmission of HIV in both men and women (Plummer et al., 1991).
Symptoms in females include mild abdominal pain, intermittent bleeding, vaginal discharge, or dysuria-pyuria syndrome. The cervix can appear normal or exhibit edema, erythema, friability, or mucopurulent discharge. In prepubertal girls, vaginitis can occur secondary to infection of transitional cell epithelium by C. trachomatis. In contrast, the squamous epithelium of the adult vagina is not susceptible to chlamydiae, and vaginal discharge generally reflects endocervical infection.
Some women develop ascending infection of the genital tract, resulting in endometritis (infection of the uterine tissues) and salpingitis (infection of the fallopian tubes). In one study, eighteen of 109 (16.5%) infected asymptomatic adolescent women followed for 2 months or more became symptomatic, but only 2 (1.8%) developed clinical pelvic inflammatory disease (PID) (Rahm et al., 1988). However, when women infected with both C. trachomatis and N. gonorrhoeae were treated with antibiotics active only against N. gonorrhoeae, 6 of 20 (30 percent) developed evidence of upper genital tract infection (Stamm et al., 1984a). Why ascending infection develops in some women with cervical infections is not known.
The definition of "pelvic inflammatory disease" is a sexually transmitted infection that ascends from the vagina and cervix to involve the uterus, ovaries, and peritoneal tissues as well as the fallopian tubes. Lower abdominal pain, usually bilateral, is the most common presenting symptom. Pain may be associated with an abnormal vaginal discharge, abnormal uterine bleeding, dysuria, dyspareunia, nausea, vomiting, fever, or other constitutional symptoms. It is more commonly present in a subclinical form that lacks the typical acute symptoms, but continues to lead to the associated long-term sequelae of infertility and ectopic pregnancy (Paavonen et al., 1982). The most important causative organisms are C. trachomatis and N. gonorrhoeae; well over half of cases are caused by one or both of these agents. Other microorganisms implicated in PID include organisms found in the abnormal vaginal flora of women with bacterial vaginosis, such as bacteroides species, anaerobic cocci, Mycoplasma hominis, and Ureaplasma urealyticum. Esch-erichia coli and other enteric organisms have also been found.
The spectrum of PID associated with C. trachomatis infection ranges from acute, severe disease with perihepatitis and ascites (Fitz-Hugh-Curtis syndrome), to asymptomatic or "silent" disease. When women with chlamydial salpingitis are compared to women with gonococcal or with nongonococcal-nonchlamydial salpin-gitis, they are more likely to experience a chronic, subacute course with a longer duration of abdominal pain before seeking medical care. Yet, they have as much or more tubal inflammation at laparoscopy (Svensson et al., 1980). Routine screening of asymptomatic women for chlamydial infection and treating those identified as infected has been shown to reduce the incidence of PID in a health maintenance organization setting (Scholes et al., 1996).
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