Tuesday, February 7, 2012

What Your Mother (and Your College) Didn't Tell You About Chlamydia

I recently read a book called, "Unprotected: A Campus Psychiatrist Reveals How Political Correctness in Her Profession Endangers Every Student." The basic premise of her book is that campus health and counseling has a bias toward presenting material in an inclusive/non-judgmental way to the point that they actually neglect to provide complete medical information. Their jobs are controlled by fear of offending or by the desire to uphold a particular ideological view. The author takes the stance that medical professionals should be delivering medical facts rather than information filtered through political opinion. The book is written anonymously, because the author believes she might experience career repercussions for stating an opinion outside the prescribed norm.

There were many points of the "Unprotected" book which did not sit well with me. For one, I think the author somewhat undervalues general sensitivity within the doctor/patient relationship and assumes that all discourse framed by an attitude of "inclusiveness" automatically leads to sugarcoating, bending, or omitting facts. I personally think it is possible to be both truthful and tactful, and I am not sure the author would agree. Even so, the book presents a compelling argument for a few issues in particular, one of which I would like to share.

I thought the most well-written chapter was the one on chlamydia, from which I actually learned something new. As it turns out, this common sexually transmitted disease can present a serious risk to fertility, not only when a person is infected, but even potentially years after treatment. I was always taught that it is a very common, pesky sort of infection, which is easily treatable with antibiotics. That's what all the pamphlets seem to say. Only women who don't go for their yearly exam need to worry about the long-term effects.

But apparently, that is only part of the story. The author claims that we do not hear about the rest of the information, because that would imply more long-lasting or permanent consequences to sexual choices. It would suggest that engaging in more "risky" behavior increases the chances of infertility, regardless of following student health mantras about getting yearly exams and treatments. To present such information to students could border on judging a person's sexual choices and is therefore out of bounds.

Based on the very plausible examples and meticulously sited statistics in the book, as well as my own experiences, I would mostly agree with her that there is a bias in the health system on many university campuses.

But even as she argues that there is an agenda at play, I recognize that her book also has an agenda of its own.

With this in mind, I consulted outside sources, such as the CDC website and medical journal articles, in addition to the statistics cited in the book itself, to find out if what she is saying about chlamydia is just the fear tactic of an extremist or the truth about the disease. And here is what I found:

According to the Center for Disease Control and Prevention (CDC), there are 19 million new STD infections every year. In 2010, 1.3 million of these were cases of chlamydia, and chlamydia is the most reported bacterial STD in the United States. The CDC also says that less than half of sexually active young women are screened annually, as recommended by the organization.

Young women are more likely than older women to contract STD's for many reasons, one of which is that the "transformation zone" on a young woman's cervix is immature. This an area where cells are more vulnerable to bacteria and viruses, and it continues to develop/shrink with age, into adulthood. This is mentioned in the "Unprotected" book and is also confirmed on the CDC website.

Further complicating the picture for young women, the author of "Unprotected" mentions a study from The Journal of Sex Research 37, no 1 (February 2000), which reported that forty percent of college women experience a sexual encounter without commitment, and ten percent report doing so more than six times. She also sites the Journal of American College Health, writing, "the most recent study of heterosexual college students showed that less than half used a condom during their last vaginal intercourse, and that was an all-time high. The reasons? There wasn't one available, there was no concern about pregnancy, the participants were high or drunk, they considered themselves uninfected, it felt better." Even those who do use condoms are still at risk, because chlamydia can live on skin that is not covered by this protection. Many women also re-contract the disease even after being treated because their untreated partner(s) still have it.

Given the shockingly high number of new cases of chlamydia each year, the specific risks to younger women, and the lack of testing being done, I wanted to get to the bottom of this idea that it can continue to affect women even if treated and eradicated.

Chlamydia is asymptomatic, or "silent," for most infected individuals. Men usually have no symptoms, but some may experience discharge from the penis or a burning sensation. If symptoms do occur for women, they usually appear within a few weeks of infection and can include abnormal vaginal discharge or a burning sensation when urinating. For women, chlamydia starts by infecting the cervix or urethra. According to the CDC fact sheet, in about ten to fifteen percent of women, untreated Chlamydia spreads to the uterus or fallopian tubes, causing pelvic inflammatory disease (PID). This can occur as soon as a few weeks after the initial infection. (So much for those yearly exams as protection against the progression of the disease.) PID also displays little to no visible symptoms, yet it can cause permanent damage, such as scarring of the upper genital area, which can lead to infertility or an ectopic pregnancy (a potentially fatal pregnancy outside the womb).

Research has indicated that once chlamydia progresses to PID, traditional antibiotic treatments may or may not actually get rid of the entire infection. More research is needed to determine the likelihood that some cases may simply remain in a dormant state once treated. This is one way chlamydia can potentially damage a woman's reproductive organs in the future.

The more striking information suggested in "Unprotected," however, is that even if the infection is completely eradicated, the chlamydial antibodies that remain in a woman's system may be linked to future miscarriages.

The reason I call this information striking is that it is rarely presented to women as a potential long-term effect of this infection. Instead, we teach that if detected early enough, we can treat Chlamydia with antibiotics before it becomes full blown PID and thus prevent potential infertility. No pathogen, no problem. Right?

Well, it's actually not always so simple.

When our body encounters a disease, we develop antibodies in our blood which help to fight the disease. These antibodies may remain in our system for months or even years, depending on the type of infection. If we contract the same disease in future, our antibodies recognize the pathogen and mount a defense against it based on their "memory" from the previous battle. They are already well versed in taking out the disease quickly. This is why, for example, most individuals can only contract chicken pox once in their lives. Their chicken pox antibodies make them immune to future attacks. Another common example is the flu vaccine, which is basically an injection of inactive flu virus, allowing a person's blood to build up a supply of antibodies. If the right strain is used for the vaccine, when the person is exposed to the real pathogen, they are ready to fight it off before it becomes a full blown case of the flu.

Similarly, a woman exposed to chlamydia will typically build up antibodies to fight the disease. Chlamydia bacteria make a type of protein called HSP, which is released when the cells in which the bacteria are hiding die. White blood cells realize HSP is an invader that does not belong in the body, and once exposed to it, they make antibodies that will specifically recognize HSP as a signal of chlamydial infection for years to come.

Interestingly enough, an important part of a human embryo's development also involves producing a type of HSP. The book "Unprotected" posits that the body of a woman previously infected with chlamydia thinks the HSP-producing embryo is another chlamydial infection and attacks, leading to a miscarriage. I was skeptical on the factual nature of this assertion, however, so I did a little side research.

A paper published by the European Society of Human Reproduction and Embryology in 2000, called "The Role of Heat Shock Proteins [HSP] in Reproduction" describes several studies from the 1990's which showed that "since bacterial and human HSP share ~50% amino acid sequence homology (Shinnick, 1991), it has been proposed that prolonged exposure by the immune system to chlamydial HSP60 and a concomitant exposure to both the chlamydial and human HSP60 may lead to autoantibody formation (Witkin, et al., 1997)." (Just so you don't get confused, I need to clarify that Witkin is one of the authors of the year 2000 "HSP in Reproduction" paper and also cites his own previous studies a number of times within the paper. Hence the pre-2000 Witkin citations within the quotes.) The paper goes on to say that other scientists have proposed specific models for how this autoantibody formation may interfere with early stages of pregnancy, ultimately causing the embryo to degenerate or undergo apoptosis.

In order to evaluate these suppositions, the authors of the "HSP in Reproduction" paper tested women undergoing in-vitro fertilization (IVF) for the presence of the anti-HSP60 chlamydia antibody. The antibody "was present in 26.3% of women who did not become pregnant after transfer, 33.3% of women with only transient biochemical pregnancies, 30% of women with spontaneous abortions, and 7.3% of women with live births (Witkin, et al., 1994)." The paper describes three other similar experiments in women undergoing IVF, in addition to studies on mouse embryonic development. Then the authors state, "In conclusion, the summarized results of these studies revealed that a previous infection with C. trachomatis (chlamydia) and a resulting immune sensitization to chlamydial heat shock protein (HSP) epitopes was associated with a poor prognosis for reproductive outcome and, in addition, impaired IVF results."

To my amazement, this is just as the author of "Unprotected" presents the information, with a few caveats.

The scientific paper does not specify how long of an exposure to chlamydia a woman must have before developing the strong immune response, so I did not see definite proof to rule out the possibility that near-immediate treatment can prevent the HSP antibody issue. That said, the half of women who do get tested are typically only tested once a year, so there is plenty of time between exams for a "prolonged" exposure. Furthermore, some women may receive false negatives in a given year, making their actual infection before treatment even longer than assumed. Just because a woman does not develope PID does not mean her infection is brief; as mentioned above, PID only develops in ten to fifteen percent of cases. And then there are the more than half of women who avoid the exam altogether for an assortment of reasons and would almost undoubtedly experience a prolonged exposure if they contracted chlamydia.

The research ultimately shows that a woman who has built immunity to chlamydia is much less likely to have a live birth in IVF. As far as scientists can tell at this point, this is the direct result of the interaction between chlamydia HSP antibodies and the embryo. These findings can be extrapolated to suggest that the chlamydia antibody is harmful to embryonic development in all pregnancies.

As I stated at the beginning of this post, I did not agree with every point in "Unprotected," but on this particular topic, I am genuinely compelled to be of the same mind as the author. The facts have long been hidden and are actually worth considering. Being a woman myself and having never heard of these potential consequences of chlamydia, I felt it was my duty to share with others. The risks you take can have an impact not just on your immediate health, but on your long-term reproductive health. There is not a magic pill for every infection, as popular culture would like us to believe. And some of the consequences are actually permanent and quite serious. They should not be glossed over in pamphlets and health centers because they make some people feel "judged" or "uncomfortable."

Just as we warn people of the risk of heart disease from being overweight and getting insufficient exercise, we should warn women of the risk of lifelong infertility from casual sex. Some people will determine the risks of overeating and sedentary lifestyle are worth it to them, just as some will prefer sexual freedom over safety. But let's not hide medical truths in order to promote a particular agenda or ideology about sexual consequences or a lack thereof. Each woman must be informed enough to weigh the risks, decide if they are worth it, and take care of the only body she will ever have.

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