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: 1161-1167Lancet 2001; 357: 1161-1167

2. Results characteristics 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. Results reproductive 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. Results health 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. Results FGC 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. Definition menstrual 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. Interpretation menstrual 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. Definition infertility 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. Interpretation infertility 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. Definition Reproductive 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. Results RTIs Trichomonas vaginalis 6.2% Candida 13% Bacterial vaginosis 37% N gonorrhoea 0% Chlamydia trachomatis 1.2% Any RTI 47% (521/1102)

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

18. Definition Pelvic 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. Definition cervical 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. Results abnormal 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. Results cervical dysplasia Low grade SIL 4.3% High grade SIL 2.3% Cervical dysplasia 6.7% (63/946)

23. Interpretation cervical 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. Definition masses Mass vulva, cervix, uterus (fibroids or uterus enlarged, irregular unspecified) and adnexae Denominator: women who had inspection/ bimanual pelvic examination

25. Results pelvic 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. Definition childbirth-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. Results any 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. Interpretation any 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