Gynecologic disease in young, sexually active women J. W. RODDICK, Spingjield,
There has been a signiJicant change in adolescent sexual behavior in the past decade. Thi.s report of 1,594 young, sexually active women, primarily from middle and upper socioeconomic backgrounds, ident$es the obstetric and gynecologic problem7 characteristic of the group. While supposedly in a low-risk categoq these patients dispkzyed a high incidence of cervical epithelial abnormality, problem pregnancy, and other obstetric awl gynecolo& abnormality. The incidence of veneral disease ~KI.Csomeu~hat lower than anticipated. (AM. J, OBSTET. GYNECOL. 126: 880, 1976.)
BOOK Adolescent sexuality i?z contemporary Sorenson7 implies that there has been a change in the “folkways and mores of adolescent sexuality” in the past five to ten years. That such changes have occurred is attested to by the proliferation of family planning agencies and veneral disease treatment facilities thoughout the nation since the mid-1960’s. The present study characterizes certain aspects of the patients seen at the Planned Parenthood Clinic of Springfield, Illinois, a midwestern city of approximately 100,000, with a rural area of about 250,000 population. The primary goal of the study was particularly to document the incidence of abnormal cervical cytology and of other problems encountered within this group, including problem pregnancy, venereal disease, and other gynecologic abnormalities. The study was undertaken in an effort to document the clinical impression that there was an inordinately high incidence of abnormal cytology among these patients. These data will be used in planning a long-range surveillance project on herpesvirus antibodies and cervical eplthelial abnormalities.
patients have been seen. Unfortunately, during the first several years, records were inadequate, cytology was done in a variety of laboratories, and follow-up was poor. Thus, only 1,594 records, consisting primarily of those currently active, were found sutiable for analysis, Each record was reviewed by the author+ and the necessary data were extracted.
Age. 0f the patients, 48.5 per cent were 18 years of age or younger; 1,455 patients (91.3 per cent) were 2-5 years old or less, and only 53 (3.3 per cent) were 30 years old or older (Fig. 1). Socioeconomic status. As these patients are almost entirely students and report only their allowance as income, assessment of their socioeconomic status is difficult, requiring an indirect method of study. B> grouping the patients into geographic clusters and utilizing addresses and zip codes, the general socioeconomic characteristics of the group were determined. Fig. 2 is a map of the city of Springfield divided into sections, roughly conforming to zip code areas 01 segments of same. While there is no ghetto area in Springfield, the area marked ‘4 comprises the lower economic location, the others varying from middle to upper levels of income. Area L’ is a high-class and upper middle-class area, Area D is the lake area which represents the highest socioeconomic locale, and areaL’ represents rural locations and small towns in the service area. The numbers in the legend indicate the per cent of the total patient group residing in the respective areas. It is apparent that only 20 per cent of the patients live in the lower socioeconomic locations. Thus, the study population differs from that of most similar studies which primarily report on inner city and ghetto neighborhoods.
Material and methods In 1970, the Sangamon County Family Planning Clinic was reorganized after a ten-year period of inactivity. This organization affiliated with Planned Parenthood in 1973. Since the reorganization, over 3,000 From the Department of Obst&cs and Gynecology, Southern Illinois UniversiQ School of Medicine. Presented by invitation at the Ninety-ninth Annual Meeting qf the American Gynecological Society, Hot Spring, Virginia, May 25-29, 1976. Reprint requests: Dr. J. W. Roddick, Jr., Southern Illinois Universi~ School of Medicine, Box 3926, Sp-ingfield, Illinois 62708.
Gynecologic disease in young ‘women
15 1413lZlllo9s765432l12 13 14 15 16
17 18 19 20 21 22 23
24 25 26 27 28 29 30+
Fig. 1. Age distribution
Marital status. Only lS0 of the patients were married; 58 were divorced, 24 were separated, and three were widows. Thus, 1,329 or 83.4 per cent of the patients were single. Pregnancy. Previous pregnancy was noted in 349 01 the patients, 182 in married or previously married women and 167 in unmarried patients. Of these, 212 had been delivered of one or more children and 178 had had one or more abortions (Table I). Few of the abortions listed were noted to be spontaneous. In addition, 154 patients were pregnant at the time of their initial visit. All but 15 in this group were single, and all but seven were referred for elective abortion. Another 17 became pregnant while attending the clinic, all but one of whom were referred for abortion (Table II). The age distribution of those patients who were pregnant at the time of their first visit to the clinic is displayed in Fig. 3 and can be seen to be similar to that of the over-all patient population, Venereal disease. Both cervical and anal cultures for gonorrhea were taken at the time of each patient’s iniCal examination and at each subsequent examination. Thayer-Martin medium was used, and cultures were quickly transported to the laboratory. Forty-five positive cultures were obtained (2.8 per cent), and three other patients reported positive gonoccoccus contacts. There were two patients with positive serology (Table III). All patients with positive cultures, contact, or serology were referred to appropriate authorities for treatment. ln Fig. 4 the ages of those with gonorrhea are compared to the age distribution of the entire
?hYkf* Previous pregnant\ Previous deIivery previous abortion
182 I 54 (53
167 58 1I 3
* Includes divorced, separated, and widowed Table
Pregnant at initial visit Subsequent pregnancy IotaI
Positive gonococcus culture Gonococcus contact Positive serolop Total
154 17 171
disease 4.5 3 2 50
group. There is a tendency for gonorrhea to be slightly more prevalent in the younger patients, a finding also reported by Zackler and associates.’ Gynecologic disease. Treatment is not provided at the Planned Parenthood Clinic of Springfield. Therefore, patients with problems must be referred elsewhere for treatment. One hundred and eighty-two patients required referral for a variety of conditions exclusive of veneral disease or abnormal cytology (Table IV). Only those patients whose vaginal dis-
Fig, 2. Map of Sprin~e~d-s~ioecon~~mic
Fig. 3. Age distribution
charge and vulvitis were truly symptomatic were refkrred for treatment. Follow-up revealed an equal mix trichomonas, and nonspecific or of candida, hacvu@d~~ vaginalis vaginitis, Most patients with minor bleeding irregularities were managed simpIy by changing their oral contraceptives. The 23 patients referred for abnormal bleeding had major problems requiring more sophisticated methods of diagnosis and treatment. One patient with abdominal pain had an ectopic
% Age Distribution % Pregnant
of All Patients
pregnancy; the majority of the rest had pelvic inflammatory disease. Abnormal cervical cytology. Cervical cytologic examination was done at the first visit on each patient and at each annual examination. Seventy-seven patients were found to have abnormal smears, the abnormality ranging from mild dysplasia to carcinoma in situ. Fifty-two of the patients with abnormal cytology were nulligravid, and only 18 had been delivered of one or
% Age Distnbutwn
of All Patents
of patients with gonorrhea.
% Age Distribution
of patients with abnormal
more babies. Only four of these patients lived in the lower socioeconomic area. Fig. 5 compares the ages of patients with abnormal cytology to the age distribution of the entire group. In this instance, although a higher percentage of abnormal smears was obtained from patients over 2 1 years of age, more than half occurred in those 21 years of age or younger. Forty-two of those with abnormal smears were examined colposcopically by the author, and directed biopsies were clone when indicated. The results of these examinations are seen in Table V. Twenty-two or 42.8 per cem had significant abnormal histology. Those patients with negative colposcopy did not have biopsy performed and are being followed at threemonth intervals by cytology and colposcopy. The remainder of the patients were seen by their private physicians, and meaningful follow-up data could not .be obtained. Comment Since young women without medical contraceptive needs rarely find their
disease in young women
problems or way to the
of All Patients by Age
gynecologist, it is unlikely that one would be able to find an adequate control group with which to compare the reported patients. Thus, any conclusions to be drawn must be made on absolute findings rather than comparative data. At the outset it is important to recall that the patients reported in this study are predominately from middle to upper socioeconomic backgrounds, They have had the advantage of good nutrition, educational opportunity, and continuous private medical care throughout their lives. This is in contrast to most similar groups studied which come from ghetto areas and are TVquently deficient in terms of medical care, hygiene. and adequacy of diet. From the socioeconom~(~ sgandpoim, therefore, this group is unique. It was startling to find that a total of 474 patients (29.7 per cent) required referral to another physician or agency for obstetric and gynecologic problems. After elimination of the problem pregnancy and abortion referrals, the number with significant problems was still 310 or 19.4 per cent. While a small number of referrals were for problems probable not related to
Vuhovaginitis Abnormal bleeding Condyloma accuminata Abdominal pain Adnexal mass Vulvar herpes Breast mass Amenorrhea Cystitis Pediculosis pubis Endometritis Hydatidiform mole Other
95 23 19 13 7 6 6 4 3 2 1 I 2
on 42 patients
Dysplasia Atypical metaplasia Carcinoma in situ Hyperkeratosis Condyloma Negative colposcopy
18 3 1 4 3 13
sexual activity or contraceptive use, the vast majority can be directly or indirectly connected to those factors. Some of the abnormalities noted might be considered relatively minor, but the incidence of venereal disease and abnormal cervical cytology were such that each must be critically examined. The 2.8 per cent discovery rate for gonorrhea in this group was lower than has been reported by others. Kates as high as 93 and 7.5 per cent have been documented.‘, ’ However, those are rates from low socioeconomic
mean that some cases are being missed, or there may truly be less gonorrhea in this population. Since cultures are frequently taken only at yearly intervals; perhaps they should be done more frequently to determine the true incidence.
Of great significance is the incidence of abno~~mal cervical cytology. While the reported incidence 01’ cytologic abnormality (48/1,000) is slightly less than that reported by Barron and Chart (57.5/1.000 itt :I 15 to 24-year-old group),’ it is considerably above that reported by Fields and associates.’ Those authors found only 1.7 abnormal smears per 1,000 paGents in medically indigent women 19 years old and vounger. If only that age group is considered in the present report, the incidence of abnormal smears is 32/ 1,000. OnI> half of the patients studied have shown histologic cvidence of intraepithelial neoplasia to date. However. if that small group were all who were so affected. the over-all rate would be 14/1,000. If only \\omen urldel 20 are considered, the incidence is 5/1.000 lvhich cxceeds that of 0.86/ 1,000 reported bv Christopherson and Parker’ in a study of low-income individuals matched for age. However, it is considerably less than the 61/ 1.000 rate reported by 0ry and associates’ in a young group from an all-black, low-income housing project. In another recent report Snyder and assoL+ ates,6 studying women mider 22 years old, fc)und abnormal cytology in 9/ 1,000 and confirmed abnormal histology in 2.7/ 1,000. The patients in that age group in the present study had an incidence of abnormal cytology of 4 I/ 1,000, with 8.5/ 1,000 showing ,some degree of dysplasia on histologic examination. a fourfold increase. The patients included in this study have previous& been thought to be at low risk for developing cervical epithelial neoplasia due to their low graviditv. ION incidence of venereal disease, and relatively high socioeconomic status. Actually this study shows that they have an incidence of cervical epithelial abnormalit), as high as or higher than that of those in the so-called “highrisk” group of previous reports. There are many individuals, groups, and agencies calling for strict cytologic surveillance of high-risk patients. The resuIts of’ this study indicate that it may be necessary to change the definition of the high-risk patient. perhaps making sexual activity a primary or sule criterion.
REFERENCES I. Barron, B. A., and Richart, R. M.: An epidemiologic study of cervical neoplastic disease, Cancer 27: 978, 1971. 2. Christopherson, W. M., and Parker, J. E.: Control of cervix cancer in women of low income in a community, Cancer 24: 64, 1969. 3. Fields. C., Restive, R. M., and Brown, M. C.: Experience in mass Papanicolaou screening and cytologic observations of teenage girls, AM. J. OBSTET. GYNECOL. 124: 730, 1976.
Keith, L., Moss, W., and Berger, G. S.: Gonorrhea detection in a family- planning clinic: A cost-benefit analysis of 2,000 triplicate cultures, AM, J. OBSTET. GYNEGOL. 121: 399, 1975. 5. Ory, H. W., Jenkins, R., Byrd, C. J., Smith, J., and Tyler, C. W., Jr.: Cervical neoplasia in residents of a low-income housing project: An epidemiologic study, AM. J. OBSTET. GYNECOL. 123: 275, 1975.
Gynecologic disease in young women
6. Snyder, R. N., Ortiz, Y,, Willie, S., and Kove, J. K.: Dysplasi:t and carcinoma in situ of the uterine cervix: Prevalence in very young women (under age 22), AM. J. OBSTW. GYNECOL. 124: 731, 1976. 7, Sorenson, R. (1.: .4d&scent Sexuality in contemporary
Discussion Montreal, Quebec, Canada. The importance of this deceptively simple paper is its implication of the health care of a group of gynecologically neglected patients, the young adolescent and voung women often too embarrassed to see her mother’s gynecologist or her family doctor and also financially unable to reach the meager facilities which are available to her. In his conclusions the author outlines two major themes. ( I) A significant incidence of gynecologic abnorm&ties in otherwise healthy young women is asso