The intrauterine device and tubo-ovarian abscess

The Impact of Age and Intrauterine Contraception on the Clinical Course of Pelvic Inflammatory Disease

BACKGROUND

The aim of the study was to investigate the clinical course of pelvic inflammatory disease (PID) and factors that could predict failed conservative treatment of PID. Additionally, the study aimed to examine the role of age and intrauterine device (IUD) use on the severity of PID.

METHOD

Fifty-one women admitted to hospital with the diagnosis of acute PID were recruited. Of those, 17 patients were subsequently operated because of failed conservative treatment. All women underwent careful examination and completed a questionnaire at admission. Their clinical course was followed and the clinician responsible for the patient completed forms at admission and at discharge. Two groups were established retrospectively, those who were treated conservatively and those who underwent surgery. The outcome results were analyzed with regard to IUD use, duration of IUD use (>or=5 or <5 years), and with regard to age below or above 35 years. All data were analyzed using the statistical package SAS. A p value <0.05 was considered significant.

RESULTS

Women who subsequently underwent surgical treatment were significantly older and significantly more frequently, current IUD users. There was no significant difference with regard to other socio-demographic characteristics. Women who subsequently underwent surgery had significantly more frequent complaints of severe abdominal pain, elevated body temperature, symptoms of peritoneal irritation, and appearance of adnexal mass. No differences were found between groups with regard to anaerobic microbiological findings, nor with regard to the finding of Actinomyces. IUD use and age >or=35 were found to be highly significant risk factors for surgery in patients with PID.

CONCLUSION

Age over 35 years and IUD use, independently of each other, were factors strongly associated with an increased risk of surgery for PID as a result of failed conservative treatment.

Microbiology and management of polymicrobial female genital tract infections in adolescents

This review describes the microbiology and management of female genital tract infections in adolescents. These infections include vulvovaginitis, vulvovaginal pyogenic infections (abscesses of Bartholin's and Skene's glands, infected labial inclusion cysts, labial abscesses, furunculosis, and hidradenitis), endometritis, pyometritis, salpingitis, pelvic inflammatory disease, and tubo-ovarian and pelvic abscess. Anaerobes can be cultured in 50% to 90% of females with a variety of genital infections and are the exclusive isolates in 20% to 50%. Obligate anaerobes are particularly common in closed-space infections, such as tubo-ovarian and vulvovaginal abscesses. The most common anaerobes found in these infections are gram-negative bacilli (especially P. bivia and P. disiens) and anaerobic cocci. Anaerobes generally are not the only pathogens found, but are usually mixed with aerobes. The most common aerobic pathogens are members of the Enterobacteriaceae family, especially E. coli, and aerobic or microaerophilic streptococci. Sexually acquired infections include Neisseria gonorrhoeae, Gardnerella vaginalis, Trichomonas vaginalis, Chlamydia trachomatis, herpes simplex, and Condyloma accuminata. Treatment regimens must provide antimicrobial coverage for N gonorrhoeae, C trachomatis, anaerobes, streptococci, and gram-negative facultative bacteria.

Postmenopausal tubo-ovarian abscess due to Pseudomonas aeruginosa in a renal transplant patient: a case report and review of the literature

BACKGROUND

Pseudomonas aeruginosa is an uncommon cause of infection in the female genital tract. We report a case of postmenopausal tubo-ovarian abscess (TOA) due to P. aeruginosa in a renal transplant recipient. The presentation included mild abdominal symptoms with rapid progression of peritonitis and surgical abscess drainage. This is the first such case in an organ transplant recipient described in the English literature.

METHODS AND RESULTS

Published reports of 1040 cases of TOA were reviewed. The most common features were a history of sexually transmitted disease or pelvic inflammatory disease, and symptoms including abdominal pain and fever. Escherichia coli, Bacteroides spp., and Klebsiella pneumoniae were the most frequently encountered pathogens. Neisseria gonorrhoeae and Chlamydia trachomatis, which are frequently isolated from cervical cultures, are uncommonly isolated from tubo-ovarian abscesses. Forty percent of patients were treated with antibiotics alone, 18.8% with abdominal surgery, and 32% with surgery and antimicrobial therapy.

CONCLUSION

This report illustrates the muted presentation and atypical microbiology of gynecologic infection in an organ transplant recipient.

Xanthogranulomatous salpingitis and oophoritis: a case report and review of the literature

A case of xanthogranulomatous salpingitis and oophoritis in a 47-year-old woman is presented. Xanthogranulomatous inflammation is an uncommon form of chronic inflammation that is destructive to affected organs; it is characterized by the presence of lipid-filled macrophages with admixed lymphocytes, plasma cells, and neutrophils. Only a few cases of xanthogranulomatous salpingitis and oophoritis have been reported to date. The case presented here is associated with Escherichia coli infection, endometriosis, and an intrauterine device.

Tubo-ovarian abscess formation in users of intrauterine devices remote from insertion: a report of three cases

Background: The association between tubo-ovarian abscess formation and the presence of an intrauterine device (IUD) is well recognized. It has been suggested that the risk of upper-genital-tract infection is highest during the immediate period following the insertion of an IUD, returning to baseline by 5 months postinsertion. We present 3 cases of women who, 10–21 years after insertion of their IUDs, developed tubo-ovarian abscesses that were not causally related to sexually transmitted diseases (STDs) or actinomycetes.

Cases: Three women, ages 39–47 years, presented to our gynecology service for evaluation of abdominal pain. One woman had bilateral tubo-ovarian abscesses and the other 2 had unilateral tubo-ovarian abscesses. All 3 were IUD users, with an interval from IUD insertion to presentation of 10–21 years. In each case, the cervical cultures for gonorrhea and chlamydia were negative at presentation and the sexual history was not consistent with an STD mode of spread. All 3 women initially received broad-spectrum antibiotics, but 2 eventually required definitive surgical therapy.

Conclusion: Long-term users of IUDs remain at risk for serious, indolent pelvic infections. These women should be counseled by their gynecologists on an ongoing basis as to this persistent risk. Tubo-ovarian abscess should be strongly considered in the differential diagnosis of an IUD user who presents with an adnexal mass, fever, or abdominal pain.

Fertility after contraception or abortion

There is a very small correlation, if any, between the prior use of OCs and congenital malformations, including Down's syndrome. There are few, if any, recent reports on masculinization of a female fetus born to a mother who took an OC containing 1 mg of a progestogen during early pregnancy. However, patients suspected of being pregnant and who are desirous of continuing that pregnancy should not continue to take OCs, nor should progestogen withdrawal pregnancy tests be used. Concern still exists regarding the occurrence of congenital abnormalities in babies born to such women. The incidence of postoperative infection after first trimester therapeutic abortion in this country is low. However, increasing numbers of women are undergoing repeated pregnancy terminations, and their risk for subsequent pelvic infections may be multiplied with each succeeding abortion. The incidence of prematurity due to cervical incompetence or surgical infertility after first trimester pregnancy terminations is not increased significantly. Asherman's syndrome may occur after septic therapeutic abortion. The pregnancy rate after treatment of this syndrome is low. The return of menses and the achievement of a pregnancy may be slightly delayed after OCs are discontinued, but the fertility rate is within the normal range by 1 year. The incidence of postpill amenorrhea of greater than 6 months' duration is probably less than 1%. The occurrence of the syndrome does not seem to be related to length of use or type of pill. Patients with prior normal menses as well as those with menstrual abnormalities before use of OCs may develop this syndrome. Patients with normal estrogen and gonadotropin levels usually respond with return of menses and ovulation when treated with clomiphene. The rate for achievement of pregnancy is much lower than that for patients with spontaneous return of menses. The criteria for defining PID or for categorizing its severity are diverse. The incidence of PID is higher among IUD users than among patients taking OCs or using a barrier method. The excess risk of PID among IUD users, with the exception of the first few months after insertion, is related to sexually transmitted diseases and not the IUD. Women with no risk factors for sexually transmitted diseases have little increased risk of PID or infertility associated with IUD use. There appears to be no increased risk of congenital anomalies, altered sex ratio, or early pregnancy loss among spermicide users. All present methods of contraception entail some risk to the patient. The risk of imparied future fertility with the use of any method appears to be low.(ABSTRACT TRUNCATED AT 400 WORDS)

A randomized comparative study of three IUDs: Nova-T, MLCu375 and MLAgCu250 in New Zealand: 1-year results

A randomized comparative study was made in New Zealand of three models of copper IUDs, the Nova-T, MLCu375 and MLAgCu250, with interval acceptors. At 1 year, the Multiloads (MLs) had lower net termination rates for accidental pregnancy, expulsion, pain/bleeding, other medical removals and infections (use-related terminations) than the Nova-T. These rates were significantly lower for the MLAgCu250 than the Nova-T for accidental pregnancy, expulsion and infection. The MLCu375 had significantly fewer removals for pain/bleeding and for other medical removals than the Nova-T. The MLAgCu250 had a significantly lower accidental pregnancy rate than the MLCu375. The Multiloads had significantly higher relevant use-related continuation rates than the Nova-T.

Uncommon problems of the double uterus

Although often asymptomatic, congenital anomalies of the uterus may be associated with many gynaecological and obstetrical problems. The double uterus should always be considered in cases of severe dysmenorrhoea and chronic pelvic pain; in cases of the failure of intrauterine contraceptive devices; in cases of a symptomatic or asymptomatic pelvic mass that is inseparable from the uterus; in cases where termination of pregnancy has been unsuccessful; and in cases of cervical incompetence. Where uterine malformations are overlooked patients may not be treated properly before excessive fetal wastage occurs and may undergo extensive surgical procedures that may terminate fertility. Clinical suspicion, accurate documentation of curettage findings and the increased use of hysterography and, especially, ultrasound enable earlier diagnoses and the application of the correct treatment.

Short-term failure of IUD removal to alter bacterial flora in a patient with chronic anaerobic endometritis

A patient with cytological and clinical evidence of IUD-associated anaerobic endometritis was studied with quantitative and qualitative bacteriological techniques. With the exception of elimination of Actinomyces israelii from the deep endocervical/endometrial culture, IUD removal induced minimal qualitative changes in the bacterial flora of the endocervical/endometrial sample during the 35 days the patient was monitored. The interposition of menstruation did not significantly alter either the quantitative or qualitative interrelationship of the bacteria present.

Taking liberties with women: abortion, sterilization, and contraception

This paper analyzes four areas in which reproductive freedom is being denied to women. The first area involves the use of sterilization without adequate counseling as to the risk of reversibility of the method or when it is made a precondition for performing an abortion. The second concerns the sterilization technique chosen, especially in developing countries, and the failure of international population agencies to note the higher complication rates of certain procedures. The third involves the inadequate information provided to women about the side-effects of the controversial injectable contraceptive, Depo-Provera. The fourth area concerns the unethical marketing of the Dalkon Shield device. It is concluded that physicians have a responsibility to avoid allowing authoritarian attitudes or racial, class, or sex prejudices to influence their treatment of women.

Acute salpingitis in the adolescent female

Acute salpingitis is an important complication of sexually transmitted disease in young women and should be considered in the differential diagnosis of abdominal pain in all young women. Many organisms, in addition to N. gonorrhoeae, have been associated with this tubal infection giving support to polymicrobial etiology. However, the exact pathophysiologic role of these organisms needs to be clearly defined. The microbiology of acute salpingitis, through direct culture from the site of infection, the fallopian tubes, needs to be clearly elucidated. Early recognition and treatment of acute salpingitis is essential in preventing the major long-term problem, involuntary infertility. Curran has estimated the reproductive outcome for a cohort of adolescent women reaching reproductive age in 1970. By the year 2000, there will have been one episode of salpingitis for every two women; 15% will be hospitalized for salpingitis with over half of these women requiring major gynecologic surgery; 10% will be rendered nonsurgically sterile; and 3% will have experienced an ectopic pregnancy. Adolescent females may be more susceptible to upper genital tract infection than older women due to possible unique biologic characteristics and sexual behaviors. Prospective microbiologically controlled studies of women with salpingitis using laparoscopy need to be developed to evaluate treatment regimens. Until such studies are undertaken, diagnosis, treatment, and fertility in women with acute salpingitis will remain unsatisfactory.

Microbial presence in the uterine cavity as affected by varieties of intrauterine contraceptive devices

A group of 33 baboons was used to study the effect of various intrauterine device (IUD) assemblies on the entrance of vaginal/cervical microflora into the uterine cavity for a total experimental period of 16 months. These animals were specially prepared surgically so that intrauterine samples could be taken aseptically and percutaneously rather than transvaginally. While the insertion and presence of any of the IUD assemblies used in this study could promote intrauterine bacteria, the principal determining factor was not the device itself, but rather retrieval tail. Multifilament tails were much more effective than monofilaments. Of particular interest is the fact that many potential pathogens can be present in the uterus for long periods in a benign, almost "normal flora" fashion without producing disease.

Actinomyces in the endometrium of IUD users

The colonization of the female genital tract with Actinomyces is closely related to the presence of an IUD in the uterine cavity. This was confirmed in the present study, which shows an Actinomyces frequency of over 3% in users of IUDs, while non-users were free from the opportunistic invader. This frequency was higher with certain types of devices than with others. None of the patients with positive results had pelvic symptoms, but cases of serious infections have been reported in the literature. The length of IUD usage appears to be directly related to the incidence of this colonization. The possible pathogenesis of pelvic actinomycosis is presented; the clinical significance of asymptomatic colonization is discussed.

Pain in gynecologic practice

This paper has given a general discussion of the spectrum of pain complaints presented to the gynecologist. Specific information about pain sensation and localization has been reviewed together with the gynecologic causes of acute abdominal pain. Chronic pain has been classified as episodic or continuous, and the causes, mechanisms, diagnosis and treatment of episodic and chronic pelvic pain have been presented. The concluding remarks have outlined some diagnostic considerations for the patient with chronic pain. (The interested reader will find more extensive information on these subjects in the articles listed in the bibliography.).

Ovarian pregnancy associated with intrauterine contraceptive devices

Four cases of ovarian pregnancy, occurring over a two-year period in the same hospital, are presented. Each case fulfills Spiegelberg's criteria. Each patient conceived with Cu-7 intrauterine contraceptive device (IUD) in situ. Review of the literature reveals an apparent increase in the frequency of ovarian pregnancy associated with IUD's. This aspect of the problem, as well as the management of this unusual type of ectopic pregnancy, is discussed. The data available do not justify a conclusion that ovarian pregnancies are caused by IUD's. Unless future studies demonstrate a cause-and-effect relationship, this may be merely an interesting coincidence. However, it seems that more than just coincidence is involved, even though the mechanism is unclear.

Genital actinomycosis and intrauterine contraceptive devices. Cytopathologic diagnosis and clinical significance

This study from a community hospital documents the relatively frequent occurrence of Actinomyces in 36 women diagnosed by Papanicolaou stained cervicovaginal smears. Actinomyces was identified exclusively in patients wearing an intrauterine or vaginal foreign body (intrauterine devices and pessaries). By using fluorescein isothiocyanate labeled antiserum, the organisms were shown to be Actinomyces israelii in eight randomly selected smears. In five cases Actinomyces was demonstrated in tissues obtained by endocervical and endometrial curettage. Anaerobic microbiologic studies performed in 11 of the 36 cases showed a relatively high rate of recovery of Actinomyces (36.3 per cent) with a yield of four positive cultures. In two cases the isolated organisms were shown to be Actinomyces israelii. In the remaining two cases the exact species of Actinomyces has remained uncertain. Of the 36 patients with smear evidence of Actinomyces, nine (25 per cent) had pelvic inflammatory disease, a rate that appears to be much higher than the already high rate among all intrauterine device users. This observation underscores the importance and clinical significance of the finding of Actinomyces in the vaginal smears of intrauterine device users. Papanicolaou stained cervicovaginal smears provide a relatively easy, inexpensive, fast, and highly specific method for the morphologic diagnosis of Actinomyces and allows us to recognize at a relatively early stage a group of patients who are potentially at risk for the development of pelvic inflammatory disease and its associated more severe complications. The hope is that prompt identification of Actinomyces in cervicovaginal smears can help to prevent the more serious infectious complications in intrauterine device users.

Oral and intrauterine contraception: a 1978 risk assessment

This report reviews the current literature on the various risks associated with the use of oral contraceptives and intrauterine contraceptive devices. Reports on oral contraceptives from large prospective studies are not beginning to supplement the detailed reports resulting from earlier case-control studies. These studies suggest that in Western societies there is an increase in the incidence of a variety of circulatory diseases, with an increased risk of death. With intrauterine contraceptive devices it now has been fairly well documented that there is an increased risk of pelvic inflammatory disease. After reviewing and assessing the risks of both methods in some detail and comparing these risks to the benefits, the resultant conclusion is that the benefits continue to outweigh the risks for both methods, except for older women who choose oral contraceptives and also are heavy smokers.

Cytologic detection and clinical significance of Actinomyces israelii in women using intrauterine contraceptive devices

Pancervicovaginal (Papanicolaou) smears exhibiting pseudomycilial-like clumps of organisms obtained from 35 women employing IUD's were studied by direct immunofluorescent technique for identification of A. israelii and A. naeslundi. In every case the specific fluorescence was achieved with species-specific antiserum against A. israelii. The clinical profile of these 35 women was retrospectively analyzed.

Pelvic abscess in association with intrauterine contraceptive device

Serious pelvic infection associated with the use of IUDs is of increasing concern to obstetricians and gynecologists. This review of the literature is accompanied by analysis of 5 years' experience at the Arizona Health Sciences Center. Of 169 patients with acute infections, 34% had an IUD in place at the onset of infection. In addition, 24 of the patients were less than 20 years of age and 35% were nulliparous. Of the nulliparous patients, 11 were rendered sterile following surgical extirpative therapy. Sixty-six patients developed pelvic and tubo-ovarian abscesses; 38% of those were related to IUD usage. Six of the pelvic abscesses and eight of the unilateral tubo-ovarian abscesses came to pelvic cleanout. Evidence presented documents the serious infection potential that IUD usage entails, the antibiotic and surgical management, the infertility that results, and the mechanism assumed responsible. In addition, the high-risk patient has been identified (young, nulliparous, sexually active, and, especially, of the lower socioeconomic strata).

New concepts in dysmenorrhea

The etiology of primary dysmenorrhea, which is the most common gynecologic complaint and cause of lost working hours, remains obscure but merits careful scientific investigation. Recent studies suggest that increased endometrial prostaglandin production and release may be responsible for dysmenorrhea. Prostaglandins cause myometrial contractility that, if excessive, leads to uterine ischemia and pain. This hypothesis has led to clinical trials of antiprostaglandin agents such as indomethacin and fenamates, which inhibit the synthesis of prostaglandin through the prostaglandin synthetase system as well as antagonize their action at the cell receptor level. The good response of dysmenorrhea to other conventional forms of therapy such as oral contraceptives and dilatation of the cervix can be partly explained on the basis of a reduced level of prostaglandins in the menstrual fluid with such therapy. There is a definite need for further evaluation of the antiprostaglandin compounds in the treatment of dysmenorrhea so that sound formulations can be evolved for the elimination of this incapacitating disorder.

Pathogenesis of acute pelvic inflammatory disease: role of contraception and other risk factors

In a case-control study of matched pairs, the risk of acute pelvic inflammatory disease (PID) was 4.4 times higher in intrauterine contraceptive device (IUD) users than in nonusers (p less than 0.001). Of approximately 500,000 cases of acute PID occurring annually in the United States, an estimated 110,000 are attributable to IUD's, costing over forty-four million dollars per year. PID was attributable to the IUD in 77 per cent of IUD users. No particular type of IUD was implicated. The relative risk of acute PID in IUD users over nonusers was higher in nulligravid women than in previously pregnant women and was directly related to socioeconomic status (SES), but the total annual risk of PID in IUD users appear inversely related to SES. IUD use significantly increased the risk of nongonococcal PID. Fever occurred in 13 (21 per cent) of 61 IUD users and 59 (41 per cent) of 143 nonusers (p less than 0.025). Among women with nongonococcal PID, and adnexal mass greater than or equal to 6 cm. was noted in 14 (40 per cent) of 35 IUD users and in only 12 (15 per cent) of 78 nonusers (p less than 0.01). An increased risk of gonococcal PID was found among non-Caucasians and women not using contraception, while the risk of nongonococcal PID was increased among women with a past history of gonorrhea. Oral contraceptive use may protect women with gonorrhea from developing PID. Menstruation precipitates the onset of symptoms of gonococcal PID.

Unilateral tuboovarian abscess: a distinct entity

In a 30 month interval at the Los Angeles County-University of Southern California Medical Center, 85 patients had tuboovarian abscesses removed that were unrelated to complications of pregnancy. Thirty-seven patients (44 per cent) of the 85 had unilateral abscesses. Twenty patients (54 per cent) of the 37 patients with a unilateral abscess were using an intrauterine contraceptive device (IUD). In 13 (65 per cent) of the 20 women using an IUD, the foreign body was a Dalkon Shield. Unilateral pelvic abscesses can occur with or without the presence of an IUD.