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The burden of reproductive disease in rural women in The Gambia, West Africa 1

The burden of reproductive disease in rural women in The Gambia, West Africa 1. Gijs Walraven Medical Research Council Laboratories, The Gambia 1 See also Lancet 2001; 357: 1161-1167. Results characteristics participants. 1,348 women participated out of 1,871 eligible (72%)

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The burden of reproductive disease in rural women in The Gambia, West Africa 1

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  1. The burden of reproductive disease in rural women in The Gambia, West Africa1 Gijs Walraven Medical Research Council Laboratories, The Gambia 1 See also Lancet 2001; 357: 1161-1167

  2. Resultscharacteristics participants • 1,348 women participated out of 1,871 eligible (72%) • Participation highest in age-groups 30-49: 80% • Participation lowest in age-groups 15-19 (63%), and 50-54 (64%) • Participation ethnic groups: Mandinka (82%), Fula (72%), and Wollof (61%)

  3. Resultsreproductive health symptoms (I) • Most common symptoms reported to field worker: menstrual problems (21%), trying to get pregnant and not succeeding (10%) abnormal vaginal discharge (7.6%), vaginal itching (8.3%). Any symptom 26%

  4. Results reproductive health symptoms (II) • Most common symptoms reported to gynaecologist: menstrual problems (34%), abnormal vaginal discharge (27%), itching or irritation vaginal area (24%), pain during sexual intercourse (14%), trying to get pregnant and not succeeding (11%). Any symptom 53%.

  5. Resultshealth seeking behaviour • A minority of women reported to have sought health care, except for ‘trying to get pregnant and not succeeding’ (61%), and ‘currently genital ulcers or sores’ (54%) • Most frequently reported reasons for not seeking care: ‘didn’t think it would help’, ‘too expensive’, ‘not serious enough’, and afraid/embarrased’

  6. Results • 16% of women had a BMI < 18.0 • 1.5% had a BMI  30.0 • 57% of pregnant women had a haemoglobin < 11 g/dL, and 51% of non-pregnant women had a haemoglobin < 12 g/dL • 2.8% of women had a haemoglobin < 8 g/dL

  7. Results • 3.2% of the women had recent/untreated syphilis • 1.7% positive for HIV (n=22; 13 HIV2, 6 HIV1, 1 dual, 2 undetermined) • 32% of women were positive for Herpes Simplex Virus 2

  8. ResultsFGC • Female Genital Cutting had been performed in 58% of the women (668/1157); 98% in Mandinka, 42% in Fula, and 3.4% in Wollof women. • 82% of the operations consisted of full clitoridectomy and removal of all or part of the labia minora • BV and presence of HSV2 antibodies were significantly higher in circumcised women.

  9. Definitionmenstrual disorders • Pain with menstrual periods that kept the woman from normal activities, irregular menstruation, spotting or prolonged bleeding in the previous three months, as reported to the gynaecologist • Denominator: Menstruating women not currently using hormonal contraceptives

  10. Results menstrual problems • Irregular cycles 16% • Dysmenorrhoea 14% • Spotting 7.3% • Heavy/prolonged bleeding 4.1% • Any menstrual problem 34% (206/603)

  11. Interpretationmenstrual problems • Menstrual problems are common, and can be disruptive to a woman’s daily life and productivity • Several effective and relatively inexpensive interventions are available

  12. Definitioninfertility • Less than 45 years of age, trying to get pregnant for at least 1 year and not succeeding reported to the gynaecologist, in spite of having regular (1/week or more) sexual contact while living with a husband and not using contraceptive methods. • Denominator: Less than 45 years of age, and presently married

  13. Results infertility • 9.8% infertility (85/871); 2.2% primary and 7.6% secondary infertility • HSG of 52 women: 18% hydrosalpinges, 23% tubal occlusion, 4% congenital uterine anomaly • 8 women had galactorrhoea, and 5 of these women had hyperprolactinaemia

  14. Interpretationinfertility • Infertility is often due to infections • Combination galactorrhoea and hyperprolactinaemia is not uncommon • Fear of infertility is a major concern to many women • Health education and promotion is the most important intervention

  15. DefinitionReproductive tract infections • Bacterial vaginosis (BV), trichomonas vaginalis, candida albicans, Gonorrhoea, or Chlamydia Trachomatis diagnosed from vaginal or cervical smears • Denominator: Women who had a vaginal and/or cervical smear

  16. ResultsRTIs • Trichomonas vaginalis 6.2% • Candida 13% • Bacterial vaginosis 37% • N gonorrhoea 0% • Chlamydia trachomatis 1.2% • Any RTI 47% (521/1102)

  17. InterpretationRTIs • WHO treatment algorithm for vaginal discharge would have overtreated women for STDs • Endogenous infections were common. • Menstrual hygiene deserves attention.

  18. DefinitionPelvic tenderness • Uterine tenderness and/or adnexal tenderness in combination with cervical excitation pain. • Denominator: Women who had a bimanual pelvic examination

  19. Results Pelvic tenderness • Uterine tenderness 18% • Adnexal tenderness 19% • Cervical excitation pain 14% • Pelvic tenderness 9.8% (102/1046)

  20. Definitioncervical dysplasia • Histological evidence of HPV infection and/or cervical precancer (equivalent to and expressed as Squamous Intraepithelial Lesions. Cytological evidence of SIL for women not undergoing further biopsy/excision • Denominator: Women who had a cervical smear

  21. Resultsabnormal cervical smears • Abnormal cervical smears: 7.4% (70/946) • Additional 3 women with SIL on punch biopsy • Of 73, 44 followed-up: cone-biopsy or LLETZ

  22. Resultscervical dysplasia • Low grade SIL 4.3% • High grade SIL 2.3% • Cervical dysplasia 6.7% (63/946)

  23. Interpretationcervical dysplasia • The results of the combined cervical cytology + histology show a very high rate of abnormality • Early detection with screening will be difficult in settings with underdeveloped health care systems • The prospect of HPV vaccination is most important

  24. Definitionmasses • Mass vulva, cervix, uterus (fibroids or uterus enlarged, irregular unspecified) and adnexae • Denominator: women who had inspection/ bimanual pelvic examination

  25. Resultspelvic masses • Tumours of the vulva 2.3% • Tumours of the cervix 4.0% • Fibroid uterus 7.4% • Enlarged uterus, irregular unspecified 5.0% • Mass adnex(ae) 1.7% • Any pelvic mass 16% (184/1155)

  26. Definitionchildbirth-related damage to pelvic structures • Genital prolapse, damaged sphincter anus (peri-anal soiling), stress-incontinence or vesico-vaginal fistula • Denominator: women who had inspection/ bimanual examination

  27. Results chilbirth-related damage to pelvic structures • Posterior or anterior prolapse 24% • Posterior and anterior prolapse 11% • Vaginal and uterine 7% • Symptoms urinary incontinence 6.8% • Functional damage anal sphincter muscle 3.0% • Vesico-vaginal sphincter 0.1% • Any problem 46% (535/1160)

  28. Resultsany reproductive morbidity • menstrual disorders 34% (30-39%) • infertility 9.8% (8.2-12%) • RTIs 47% (44-51%) • pelvic tenderness 9.8% (7.0-14%) • cervical dysplasia 6.7% (5.2-8.4%) • masses 16% (13-20%) • damage pelvic structures 46% (40-52%) • Any repro morbidity 70% (67-74%)

  29. Interpretationany reproductive morbidity • There is a large burden of disease, partly ‘silent’ • Empowerment of women through education is a key factor to improved reproductive health • Serious reforms in reproductive health services are needed to stimulate and meet the demand

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