Proc. roy. Soc. Med. Volume 68 April 1975

Occasionally diseases other than those listed above may be transmitted sexually, as for example vaccinia of the vulva (McCann et al. 1974). Finally it is unfortunate in the present state of knowledge that contraception does not necessarily provide simultaneous protection against pregnancy and sexually transmitted disease. It is important therefore that gynaecologists instruct their patients to the effect that barrier methods give protection against pregnancy and sexually transmitted disease, but intrauterine contraceptive devices and oral contraceptives against pregnancy only. Conclusion It is clear that there is a close relationship between venereology and gynecology, and this relationship should be emphasized both in undergraduate and postgraduate training. Thus the Joint Committee on Contraception of the Royal College of Obstetricians and Gynecologists and the Royal College of General Practitioners have stated that a lecture on sexually transmitted disease must be included in recognized training for their certificate. Indeed, the subject might with advantage become necessary training for


Berfeld W K (1972) British Journal of Venereal Diseases 48, 144 Fiumara N J (1972) British Journal of Venereal Diseases 48, 308 Kenney A & Greenhalf J 0 (1974) British Medical Journal i, 519 McCann J S, Harris J R W & Mahony J D H (1974) British Journal of Venereal Diseases 50, 155 Morse A R, Coleman D V & Gardner S D (1974) Journal of Obstetrics and Gynacology of the British Commonwealth 81, 393 Nahmias A J, Josey W E, Naib Z M, Freeman M G, Fernandez R J & Wheeler J H (1971) American Journal ofObstetrics and Gynecology 110, 825 Naib Z M, Nahmias A J, Josey W E & Wheeler J H (1970) Obstetrics and Gynecology 35, 260 Nicol C S (1971) British Medical Journal ii, 328 Rawls W E, Kaufman R H & Gardner H L (1972) Clinical Obstetrics and Gynecology 15, 919 Roberts J K (1973) Journal of Obstetrics and Gynarcology of the British Commonwealth 80, 188 Silverstone P I, Snodgrass C A & Wigfield A S (1974) British Journal of Venereal Diseases 50, 53 Willcox R R (1972) British Journal of Venereal Diseases 48, 163

Dr E M C Dunlop (The London Hospital, London El IBB; Moorfields Eye Hospital; and Institute of Ophthalmology, London)

Some Aspects of Sexually Transmitted Diseases Today In 1972, 65 895 cases of nongonococcal urethritis (NGU) in men were reported in England and Wales; this compared with 54 974 cases of general practitioners. gonorrhea in men, women, and children (DHSS All gynecologists therefore should familiarize 1973, Welsh Office 1973). The incidence of nonthemselves with the conditions they are likely to gonococcal infection in men, women and children encounter and with the facilities offered by the together would be likely to be at least 130 000, special clinics. Moreover, it is suggested to trainee making it the commonest of the sexually transgynmcologists that a period of observation and mitted infections in England and Wales. In training in a special clinic is an excellent way of contrast, only 1695 cases of early infectious gaining practical experience not only of sexually syphilis (primary, secondary and early latent) transmitted diseases but also of 'everyday were reported. Thus, early syphilis is a well gynecology'. In addition, the Royal College of controlled disease here while gonorrheea and Obstetricians and Gynecologists has recently NGU have been steadily increasing in incidence. agreed that work in a department of venereology It is a paradox that these dangers are becoming would be acceptable for the elective year of commoner at a time when a larger number of training for the MRCOG. Previous gyn=co- effective remedies are available for them than logical experience provides an excellent basis for ever before. It seems likely that the ready work in venereology, and indeed the MRCOG availability of these remedies may even militate has been accepted as a suitable qualification for against effective control. Thus, the latest antientry into the specialty. Conversely, trainee biotic or chemotherapeutic agent may be prevenereologists would certainly benefit from an scribed for a patient because of dysuria or disopportunity to gain further gynecological ex- charge due to genital infection. But, unless such perience, and, with this in view, it may be that treatment is preceded by an accurate diagnosis, liaison could be made between departments of there can be no effective follow up to determine obstetrics and gynecology and departments of that cure has taken place, neither can contact venereology for reciprocal training in out-patient tracing of sexual partners be carried out. clinic work. This of course would be a matter for In contrast to this both patient and doctor local arrangement. Modern gynecology has now still regard syphilis with respect. This means that been extended to include family planning and if a man develops a penile sore that may be due to psychosexual problems. Sexually transmitted syphilis he attends a clinic for investigation. If disease is another important aspect which must syphilis is diagnosed, appropriate treatment is be included if present-day gynaecologists are to given, contacts are traced and patients are followed keep abreast of current and future developments. up after treatment. As there are over 200 clinics for sexually transmitted disease in the UK all [This paper is to be published in full in another patients have ready access to skilled specialist advice, and syphilis remains well controlled. journal.]


The situation in the United Kingdom can be contrasted with that obtaining in the United States of America (Dunlop 1974b, American Social Health Association 1973). There it was thought that 'penicillin was the magic word' (Brown 1960) that would eradicate venereal disease so the venereal disease service was largely dismantled. Now the incidence of both gonorrhoea and of syphilis are at unprecedented heights there despite the return to serious attempts at control. The population of the USA is approximately four times that of England and Wales where, in 1972, there were 1695 cases of early syphilis. With this rate the USA should have had 6800 cases, but they had 44 354 reported cases and no fewer than 85000 estimated cases of primary and of secondary syphilis alone. This last figure is due to the fact that most patients in the USA (unlike England and Wales) are treated outside the clinic system and so are not included in the reported figures. In 1972 in England and Wales there were 54 974 cases of gonorrhoea; in the USA there were 718 401 cases (instead of 220 000) and the estimated number of cases was 2.5 million. That eminently preventable disease early congenital syphilis was increasing in the USA, although vanishing in the UK. There are many changing social factors. Thus, paid prostitutes are the sources of only 14% of cases of gonorrhoea diagnosed at The London Hospital, compared with 31 % in 1960; 'girlfriends' are the sources in no less than 49 %, compared with 27 % in 1960 (Dunlop et al. 1971). The 'girlfriend' is more accessible to contact tracing than the prostitute so this change makes the contact tracer more effective. In 1960, prior to the use at The London Hospital of contact tracers for gonorrhoea, of 111 women who had had intercourse with 100 men suffering from gonorrhoea only 12 attended a clinic. When contact tracers were employed, of 125 such women, 54 attended a clinic. This improved attendance was sufficient to reduce the number of cases of gonorrhoea at The London Hospital (because of the decrease in the- number of infected men) at a time when the national incidence was increasing sharply (Dunlop et al. 1971). Only 22% of women with gonorrhoea attend a clinic because of their own symptoms (Dunlop 1963). Having run a risk (not the presence of symptoms) must be the indication for attendance for tests, and this point must be made in public education. Since Neisser described the gonococcus in material from the eyes of newborn babies, and in genital material from adults, advances in microbiology have shown an increasingly close relationship between conjunctivitis and genital infection. Ophthalmia neonatorum and conjunctivitis in the adult (due to gonorrhoea and to TRIC agent)

Section of Obstetrics & Gynacology


indicate the presence of genital infection. Culture in irradiated McCoy cells is a more sensitive test for Chlamydia (Gordon et al. 1969, Dunlop et al. 1969, Darougar, Dwyer, Treharne, Harper, Garland & Jones 1971, Darougar et al. 1972, Philip et al. 1971) than culture in yolk sac and the examination of smears. The method has been simplified and refined (Darougar, Kinnison & Jones 1971, Darougar et al. 1972). The relationship of Chlamydia to genital infection has been reviewed (Dunlop 1974a). Chlamydia may now be isolated from urethral material from up to 45 % of men with 'nonspecific' urethritis, and from cervical, urethral and rectal material from the sexual partners of such men (Dunlop et al. 1972). It may be recovered from such material from the mothers of babies suffering from TRIC ophthalmia neonatorum, and from urethral material from the fathers. The infected fathers would otherwise be considered to have nonspecific urethritis (NSU). TRIC agent may similarly be recovered from men and women who present because of ocular infection by the agent, and from the sexual partners of such people. Genital transmission seems to be the common route of infection in the developed world so that TRIC ocular infection (apart from ophthalmia neonatorum) is characteristically a disease of young adults. In contrast, in areas in which conditions are such that trachoma is hyperendemic, transmission there is from eye to eye in early childhood. The presence of Chlamydia is associated with inflammatory changes from which it may be isolated, and in which it may be found by electron microscopy. In studies of controls it has not been isolated from material obtained with a curette or endourethral swab from men free from urethritis (Oriel et al. 1972, Vaughan-Jackson 1974). Urethritis has been established experimentally, by inoculating the urethra with agent, in a male monkey (Smith et al. 1973) and in a male baboon (Darougar, Kinnison & Jones 1971); agent was re-isolated from the inflamed urethra in each case. It seems that a considerable proportion of 'nonspecific' genital infection is due to Chlamydia. Members of this genus are not viruses; they respond best to treatment with tetracyclines and

sulphonamides. REFERENCES American Social Health Association (1973) Annual Report: Today's VD Control Problem Brown W J (1960) In: Syphilis. Modern Diagnosis and Management. Public Health Service Publication No. 743, Washington; p III Darougar S, Dwyer R St C, Treharne J D, Harper I A, Garland J A & Jones B R (1971) In: Trachoma and Related Disorders. Ed. R L Nichols. Excerpta Medica, Amsterdam; p 445 Darougar S, Jones B R, Kinnison J R, Vaughan-Jackson J D & Dunlop E M C (1972) British Journal of Venereal Diseases 48, 416 Darougar S, Kinnison J R & Jones B R (1971) In: Trachoma and Related Disorders. Ed. R L Nichols. Excerpta Medica, Amsterdam; pp 63, 501


Proc. roy. Soc. Med. Volume 68 April 1975

Department of Health and Social Security (1973) On the State of the Public Health. The Annual Report of the Chief Medical Officer of the DHSS for the year 1972. HMSO, London Dunlop E M C (1963) British Journal of Venereal Diseases 39, 109 (1974a) In: Tenth Symposium on Advanced Medicine. Ed. J G G Ledingham. Pitman Medical, London; p 409 (1974b) American Heart Journal 88, 395 Dunlop E M C, Hare M J, Darougar S, Jones B R & Rice N S C (1969) Journal ofInfectious Diseases 120, 463 Dunlop E M C, Lamb A M & King D M (1971) British Journal of Venereal Diseases 47, 192 Dunlop E M C, Vaughan-Jackson J D, Darougar S & Jones B R (1972) British Journal of Venereal Diseases 48, 425 Gordon F B, Harper I A, Quan A L, Treharne J D, Dwyer R St C & Garland J A (1969) Journal ofInfectious Diseases 120, 451 Oriel J D, Reeve P, Powis P, Miller A & Nicol C S (1972) British Journal of Venereal Diseases 48, 429 Philip R N, Hill D A, Greaves A B, Gordon F B, Quan A L, Gerloff R K & Thomas L A (1971) British Journal of Venereal Diseases 47, 114 Smith D E, James P G, Schachter J, Engleman E P & Meyer K F (1973) Arthritis and Rheumatism 16,21 Vaughan-Jackson J D (1974) quoted by E M C Dunlop in: Tenth Symposium on Advanced Medicine. Ed. J G G Ledingham. Pitman Medical, 1London; p 409 Welsh Office (1973) Communication from Welsh Office, Cathays Park, Cardiff ,CFI 3NQ

Dr Albert Singer (Jessop Hospitalfor Women, Sheffield, S3 7RE)

Cervical Dysplasia in Young Women Epidemiological evidence suggests that women possessing certain behavioural characteristics are at an increased risk for developing cervical precancer (i.e. dysplasia and in-situ carcinoma) and cancer (Lombard & Potter 1950, Reid 1965, Wynder 1969). These characteristics are 'youthful promiscuity', marital instability, aDd pregnancy. The common denominator of all these factors is coitus. This disease seems to be venereally transmitted with no lesion ever having been reported in a virgin woman (Rotkin 1973). An early age of first intercourse with an increased number of sexual partners seems to be related in some way to the genesis of this malignancy. It was therefore decided to perform a multidisciplined study which examined the cervices of women who had these characteristics. Since girls and women with these qualifications tend to constitute the majority of inmates confined to prison, 920 of them (mean age 24.8 years, range 16-64) were randomly selected and 768 of these voluntarily underwent colposcopic, cytological and venereological examination. Punch biopsy of all atypical transformation zones detected colposcopically should theoretically sample all lesions with a neoplastic potential existing within the cervix (Coppleson & Reid 1967). This allows a true prevalence rate for dysplasia and in-situ cancer to be determined in this population. This rate would be more accurate than that obtained by cytological screening. A satisfactory biopsy was obtained in '88 % (324) of cases with an atypical transformation zone. The


latter finding occurred in 48 % (368) of cervices subjected to colposcopy. A prevalence rate of dysplasia (mild to severe) of 8.6 % existed in this population, the rate being about seven to ten times that usually reported in other studies (Stem 1969). It did not vary with age but was increased by the parous state. Young prostitutes possessed the highest rate of the more major types of dysplasia while girls who were unemployed and convicted of vagrancy and drug offences had a large number of the minor dysplastic lesions. It is speculated that the former type represents long-term, and the latter short-term, exposure to 'promiscuous' behaviour. A common histological finding in cervical biopsies of these women was of epithelial infiltration and destruction by inflammatory and 'immunologically active' cells. This reaction varied according to the presence or absence of certain social and sexual variables. It may indicate a rejection mechanism against a coitally transmitted mutagen. Current teaching insists that some of these lesions contain a neoplastic potential (Coppleson & Reid 1967). Recent evidence (Beral 1974) indicates that a dramatic increase in their frequency is likely. As such, sexual 'promiscuity' in young women does have and will have some penalties. Its recognition, handling and solution provide us with a major problem (Singer 1974). [A full description of this study will appear elsewhere at a later date.] Acknowledgments: This study was conducted in conjunction with Dr Margerita Stevenson, Home Office, London; Dr Gerry Slavin, Clinical Research Centre, Northwick Park Hospital, Harrow, Middlesex; Dr Hugh Cowdell, Radcliffe Infirmary, Oxford, and Mr Peter Smith, DHSS Cancer Trials Unit, Oxford. One of us (A S) was in receipt of a Medical Research Council project grant (G 971/212/c). The advice and encouragement of Sir John Stallworthy is gratefully acknowledged. REFERENCES. Beral V (1974) Lancet i, 1037 Coppleson M & Reid B L (1967) Preclinical Carcinoma of the Cervix Uteri. Pergamon, Oxford Lombard H & Potter E A (1950) Cancer 3,960 Reid B L (1965) Medical Journal of Australia 1, 375 Rotkin I (1973) Cancer Research 33, 1353 Singer A (1974) British MedicalJournal ii, 41 Stern E (1969) Obstetrical and Gynecological Survey 24, 711 Wynder E (1969) Obstetrical and Gynecological Survey 24, 697

The following paper was also read: Counselling Young People with Sexual Difficulties Mrs Sheila King Lassman (Offthe Record Youth Counselling Service, 5 Woodhouse Road, London N12)

Some aspects of sexually transmitted diseases today.

234 Proc. roy. Soc. Med. Volume 68 April 1975 Occasionally diseases other than those listed above may be transmitted sexually, as for example vaccin...
591KB Sizes 0 Downloads 0 Views