Chlamydia, the Silent STD That Can Cause Infertility

One of the biggest frustrations in public-health circles today involves a tiny bacterium called Chlamydia trachomatis.

Chlamydia infection is the most common sexually transmitted disease, responsible for a record 1.1 million cases reported to the Centers for Disease Control and Prevention in 2007, and experts there estimate that twice that many cases go undetected. Left untreated, chlamydia can cause infertility or potentially fatal ectopic pregnancies. But many women aren’t even aware that they were exposed to it—possibly years ago—until they try to have a baby and can’t.

Chlamydia can be detected with a simple urine test. It can be treated with a single dose of antibiotics, and the CDC has been urging all sexually active women under 26 years old to be tested for it annually, as well as older women who have had a change of sexual partner. Yet fewer than 40 % of women in those categories are being screened. “You’d think this would be a no-brainer,” says John Douglas, director of the CDC’s division of STD prevention. “That’s why we’re trying to get the message out.”

The CDC, along with the National Chlamydia Coalition, an umbrella group of nearly 40 medical associations, are working to spread the word about the importance of screening for chlamydia, which is also a key topic at this week’s meeting of the International Society for STD Research in London.

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The bacteria often go undetected, but are easy to test for and treat.

Chlamydia is especially prevalent among women ages 15 to 19 and African-Americans, but sample studies have found the infection in nearly 10% of all female Army recruits, 10% of female college freshmen and 14% of women in managed-care plans. Experts say it’s about three times as prevalent in women than men, but it may be that men eliminate it from their bodies more readily, while it goes on to cause far more damage in women.

Efforts to screen for chlamydia have run into a number of obstacles. One is simple awareness: Chlamydia is less well known than other STDs. “I see people in my clinic who can barely pronounce the word,” says Sabrina Kendrick, director of the STD screening clinic at John H. Stroger Jr. (formerly Cook County) Hospital in Chicago. And many patients don’t think to ask about it since the few symptoms it causes—occasional vaginal discharge, bleeding between periods, painful intercourse and pelvic pain in women, and burning upon urination in men—are vague and can have many other causes.

Many primary-care doctors may be too time-pressed to bring up chlamydia screening during office visits. And some don’t think chlamydia could be a problem in their middle-class practices. But that’s wrong, experts say. “Models have this. Businesswomen have it. I see it all the time,” says Miklos Toth, an obstetrician/gynecologist whose practice is on Park Ave. in Manhattan.

Many girls in the prime chlamydia age group are under the care of pediatricians, who may be uncomfortable bringing up sex with patients they’ve treated since infancy. Even when pediatricians discuss the human papilloma virus (HPV) vaccine with adolescents and parents, it’s often in the context of preventing cancer in the future, not current sexual activity. “A lot of health-care providers aren’t making the connection when they are dealing with adolescents,” says Lynn Barclay, president of the American Social Health Association, a nonprofit public-health advocacy group. “But to pretend that teenagers aren’t having sex is very dangerous.”

All 50 states allow minors to be tested and treated for STDs without a parent’s consent, but paying for it can be tricky. If a young patient is covered on the family insurance plan, having the lab fee appear on an Explanation of Benefits report can be a breech of confidentiality. So some doctors suggest paying in cash—a chlamydia test runs between $40 and $90—or referring young patients to STD or family-planning clinics that offer the test at a low or no cost. Getting screened “is a lot less than the cost of fertility treatments,” says Dr. Douglas.

A for-profit start-up company called GetSTDTested.com last month launched a Web site with the same name that refers people 18 years old and over to local labs for chlamydia and other STD tests. The site allows users to obtain a doctor’s order, pay for the tests and get confidential results online. (If you test positive, you need to obtain antibiotics on your own but the site provides referrals.) The company has also produced a fictional Web-isode series, called “The O Mission,” to help spread the word about chlamydia.

A pilot program partly funded by the CDC at Johns Hopkins University enables residents of Maryland, West Virginia, the District of Columbia, Denver and parts of Illinois to request free kits online (at www.Iwantthekit.org) that let them test for chlamydia at home—women with a vaginal swab; men with a urine test and penile swab. They return the kits and get results via phone, email or regular mail. The free kit program “could go nationwide if we can get funding,” says Charlotte A. Gaydos, a professor of infectious diseases at Johns Hopkins, who has been running the program and studying the results. This month, Los Angeles County started a similar program offering free at-home tests for female residents ages 15 to 25.

Even when women are treated for chlamydia, about 25% become reinfected within six months—probably due to a partner who wasn’t treated. So the CDC recommends that doctors give women a second course of antibiotics for their partners, even without being seen by a doctor themselves. It can be treated either with a weekly dose of doxycycline or a single dose of azithromycin, which goes by the brand name Zithromax, made by Pfizer Inc., in many countries.

 

A Scene From 'O Mission'

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Watch a trailer for "O Mission," an online series that promotes chlamydia awareness. Video courtesy of Octane Rich Media.

Chlamydia can be spread by oral or anal sex, as well as vaginal sex; condoms greatly reduce the transmission rate. No one knows for sure how long an infected person remains contagious. But experts advise caution. “If I haven’t had sex for a while am I still at risk of having an infection that can be spread? Yes,” says Dr. Douglas. “An asymptomatic infection that can persist for an indefinite period of time raises a lot of questions.”

More insidiously, even when a woman no longer tests positive for an active infection, the chlamydia bacteria may have moved into her upper genital tract and set off pelvic inflammatory disease. PID can cause pelvic pain—or it can be asymptomatic—but it often leaves inflammation and scar tissue that blocks a woman’s fallopian tubes, preventing fertilization. PID is also the most common cause of ectopic pregnancy, which can be fatal. “It’s not the infection itself but the body’s response to get rid of the bacteria that causes the scarring,” says Dr. Toth. “And even if just some fragments of the bacteria remain, the immune system thinks an active infection is still present.”

Dr. Toth says he has also found evidence of old chlamydia infections in women with endometriosis—a condition in which bits of uterine lining tissue grow outside the uterus, which can also cause pain and infertility. He also believes that chlamydia infecting the uterine wall can cause miscarriages, and that it can invade ovaries and lead to early ovarian decline and early menopause. Such scarring can sometimes be seen with a hysterosalpingogram, an X-ray of the uterus and fallopian tubes. Telltale changes in blood flow can also be seen on a three-dimensional ultrasound. PID can be treated with antibiotics; sometimes an intravenous dose is necessary. But severe scar tissue may need to be removed surgically before a woman can get pregnant or to resolve pelvic pain.

Most official efforts are focused on detecting active chlamydia infections in young women. But what if you think you were exposed years ago? The main risk is to fertility. The CDC recommends that all pregnant women be tested for chlamydia at the first prenatal visit, although if you are planning to become pregnant, it’s a good idea to be tested for all STDs well in advance. Older women who are experiencing pelvic pain, intermittent bleeding, unusual vaginal discharge or signs of early menopause should ask their doctor if chlamydia could be involved.

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