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

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%)

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%

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%.

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’

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

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

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.

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

Results menstrual problems

• Irregular cycles 16%

• Dysmenorrhoea 14%

• Spotting 7.3%

• Heavy/prolonged bleeding 4.1%

• Any menstrual problem 34% (206/603)

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

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

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

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

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

ResultsRTIs

• Trichomonas vaginalis 6.2%

• Candida 13%

• Bacterial vaginosis 37%

• N gonorrhoea 0%

• Chlamydia trachomatis 1.2%

• Any RTI 47% (521/1102)

InterpretationRTIs

• WHO treatment algorithm for vaginal discharge would have overtreated women for STDs

• Endogenous infections were common.

• Menstrual hygiene deserves attention.

DefinitionPelvic tenderness

• Uterine tenderness and/or adnexal tenderness in combination with cervical excitation pain.

• Denominator: Women who had a bimanual pelvic examination

Results Pelvic tenderness

• Uterine tenderness 18%

• Adnexal tenderness 19%

• Cervical excitation pain 14%

• Pelvic tenderness 9.8% (102/1046)

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

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

Resultscervical dysplasia

• Low grade SIL 4.3%

• High grade SIL 2.3%

• Cervical dysplasia 6.7% (63/946)

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

Definitionmasses

• Mass vulva, cervix, uterus (fibroids or uterus enlarged, irregular unspecified) and adnexae

• Denominator: women who had inspection/ bimanual pelvic examination

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)

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

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)

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%)

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