Pelvic inflammatory disease and tubal infertility: the preventable conditions

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

Body size and time-to-pregnancy in black women

STUDY QUESTION

Are overall and central obesity associated with reduced fecundability in US black women?

SUMMARY ANSWER

Overall and central obesity--based on self-reported measures of body mass index (BMI, kg/m(2)), waist circumference and waist-to-hip ratio--were independent risk factors for subfertility in our cohort.

WHAT IS KNOWN ALREADY

Overall obesity (BMI ≥ 30 kg/m(2)) has been associated with infertility in several studies. The role of central obesity is less clear. There are no previous studies of time-to-pregnancy (TTP) in black women.

STUDY DESIGN, SIZE, DURATION

Data were derived from the Black Women's Health Study, a prospective cohort study. During 1995-2011, there were 2239 planned pregnancy attempts reported by 1697 women, resulting in 2022 births. Cohort retention was greater than 80%.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Eligible women were aged 21-40 years and reported at least one planned pregnancy attempt during 1995-2011. Height and weight were reported in 1995, with weight updated every two years; waist and hip circumferences were reported in 1995 and updated in 2003. A validation study within the cohort showed high correlations between self-reported and technician-measured weight (r = 0.97), height (r = 0.93), waist circumference (r = 0.75) and hip circumference (r = 0.74). In 2011, TTP was reported in months. Proportional probabilities regression models were used to estimate fecundability ratios (FRs) and 95% confidence intervals (CI), adjusting for covariates.

MAIN RESULTS AND THE ROLE OF CHANCE

High BMI was associated with delayed conception: relative to BMI 18.5-24.9, FRs for BMI categories of <18.5, 25.0-29.9, 30.0-34.9 and ≥ 35.0 were 0.92 (CI: 0.64-1.32), 0.93 (CI: 0.84-1.03), 0.92 (CI: 0.79-1.06) and 0.73 (CI: 0.61-0.87), respectively. Associations were stronger among nulliparous women (P-interaction = 0.003). After controlling for BMI, reduced fecundability was observed among women with large waist circumferences (≥ 33 versus <26 inches: FR = 0.73, CI: 0.60-0.88) and large waist-to-hip ratios (≥ 0.85 versus <0.71: FR = 0.83, CI: 0.71-0.97).

LIMITATIONS, REASONS FOR CAUTION

TTP was reported retrospectively and error in recall is likely, particularly as time since the pregnancy increases. However, results were similar when based on the most recent versus first pregnancies. Confounding may have been introduced by the lack of control for important determinants of TTP. Nevertheless, control for maternal age and education, which are highly correlated with TTP determinants such as paternal age and persistence in trying, should reduce the extent of confounding. The analysis was confined to planned pregnancies. If pregnancy intention was related both to body size and fecundability, our results could be biased. Bias is likely to be small because we found little difference in body size and other measured characteristics between pregnancy planners and non-planners.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings add to the growing body of literature showing that excess BMI is associated with reduced fecundability and further suggest that central obesity is an important independent risk factor for infertility. The relation of obesity to infertility is especially relevant to US black women because they have higher rates of obesity and infertility. Reductions in overall and central obesity may offer the potential to improve fertility outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by National Cancer Institute grant CA58420. We have no competing interests to report.

Prevalence and correlates of rectal Chlamydia and gonorrhea among female clients at sexually transmitted disease clinics

BACKGROUND

The prevalence and correlates of rectal sexually transmitted infections are well described among men who report receptive anal intercourse (AI); however, little is known about the epidemiology of rectal sexually transmitted infections among women.

METHODS

We conducted a cross-sectional study of women attending public sexually transmitted disease clinics in Los Angeles County, California. Women were eligible for inclusion in this study if they reported AI in the previous 90 days, were tested for rectal chlamydia and gonorrhea, and were seen between January 2008 and December 2010.

RESULTS

Among the 2084 clinic visits by women in this analysis, chlamydia and gonorrhea percent positivity by anatomic site was 12% (n = 144) for urogenital chlamydia, 14.6% (n = 171) for rectal chlamydia, 3.3% (n = 66) for urogenital gonorrhea, and 3.0% (n = 60) for rectal gonorrhea, with 25% of chlamydia cases and 19% of gonorrhea cases having rectal-only infections. Among women 25 years or younger, rectal infections were higher in visits in which women reported sex with an injection drug user (46.5% vs. 15.5%; P < 0.01) or sex with a HIV-positive partner (66.7% vs. 15.8%; P = 0.02). Among women older than 25 years, rectal infections were higher in visits where women reported substance use (10.6% vs. 5.8%; P ≤ 0.01). In multivariable models controlling for age and the presence of a urogenital infection, these associations remained.

CONCLUSIONS

Chlamydia and gonorrhea positivity was high among women reporting AI, and a large proportion of these cases would be missed in the absence of rectal testing. The high-risk behaviors of women with rectal infections highlight the need for rectal screening recommendations.

Sexual behaviors after universal screening of sexually transmitted infections in healthy young women

OBJECTIVE

To prospectively study the relationship between diagnosis of sexually transmitted infections (STIs) at entry to U.S. Marines recruit training and subsequent sexual behaviors during vacation.

METHODS

Of all women entering recruit training (June 1999-June 2000), 2,157 (94%) voluntarily enrolled. At baseline, women received universal screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis and treatment and counseling for positive STIs. Recruit training (13 weeks) precluded any social activities. Unrestricted vacation followed (median 10 days). After training resumed (3 weeks), questionnaires and repeat STI screening were administered. Multivariable logistic regression examined STI diagnosis at baseline as a predictor for risky sexual behaviors at vacation and STI-positive diagnosis after vacation.

RESULTS

The study was completed by 1,712 (79%) women (median age 18 years); 1,038 reported sexual activity during vacation; 71% used condoms inconsistently; 19% had casual partners. At baseline, 152 (15%) tested STI-positive. Baseline STI diagnosis was unrelated to inconsistent condom use, nonmonogamous partnerships, or multiple partnerships. However, women testing STI-positive at baseline were more likely to test STI-positive after vacation (adjusted odds ratio 3.74, 95% confidence interval 2.10-6.65). Baseline STI diagnosis predicted casual partnerships among women aged 19-21 years (adjusted odds ratio 2.48, 95% confidence interval 1.12-5.50).

CONCLUSION

Substantial numbers of women engaged in risky sexual behaviors after universal STI screening and counseling. Compared with STI-negative women, STI-positive women were at increased risk for subsequent STI acquisition regardless of their similar behaviors. As universal STI screening is increasingly implemented, follow-up care will likely be required to further reduce risky behaviors and address network-level factors.

LEVEL OF EVIDENCE

II.

Preferences for fertility in women with pelvic inflammatory disease

OBJECTIVE

To identify the value that women with pelvic inflammatory disease (PID) assign to the health impact of future infertility.

DESIGN

Cross-sectional observations on patient preferences.

SETTING

Participants in an existing multicenter clinical trial of PID treatment options.

PATIENT(S)

Five hundred thirty-two women with signs and symptoms of PID who were identified from emergency departments and sexually transmitted disease clinics.

INTERVENTION(S)

Women were asked to rate whether life with future infertility was more or less meaningful than life with each of seven chronic health conditions: sinus congestion, insomnia, chronic headache, asthma, incontinence, dialysis, and paralysis.

MAIN OUTCOME MEASURE(S)

Preferences regarding future infertility.

RESULT(S)

Most respondents rated future infertility as being worse than sinus congestion and asthma but better than the health impact of incontinence, dialysis, and paralysis. There was a wide range of opinion, with 18% viewing future infertility as minor (better than all conditions) and 5% viewing it as extremely important (worse than all conditions). Future infertility ratings were influenced by race, parity, difficulty in conceiving, and views on the importance of future pregnancy.

CONCLUSION(S)

The majority of women with PID rate future infertility as a significant issue. Optimizing access to infertility treatment may affect the quality of life for such women.

A refined estimate of the average lifetime cost of pelvic inflammatory disease

BACKGROUND

The major complications of pelvic inflammatory disease (infertility, ectopic pregnancy, and chronic pelvic pain) are the leading cause of non-HIV sexually transmitted disease morbidity in the United States.

GOAL

The goal of the study was to estimate a plausible range for the average lifetime cost of pelvic inflammatory disease (PID) and its major complications in a cohort of U.S. women of reproductive age.

STUDY DESIGN

We developed a state-transition computer-based model to simulate the natural history of PID, incorporating the severity of infection, number of recurrent episodes, treatment setting, and the risk over time of major complications. Clinical and cost data were from the published literature. Model outcomes included life expectancy, quality-adjusted life expectancy, and lifetime costs.

RESULTS

In a cohort of 100,000 females acquiring PID between 20 and 24 years of age, 8550 ectopic pregnancies, 16,800 cases of infertility, and 18,600 cases of chronic pelvic pain were projected to occur. Assuming a 3% annual discount rate, we found the average per-person lifetime cost to be $2150. Average lifetime costs for women who developed major complications were $6350 for chronic pelvic pain, $6840 for ectopic pregnancy, and $1270 for infertility. The majority of costs (79%) were accrued within 5 years of upper genital tract infection. Results were most sensitive to assumptions about the timing of major complications and the discount rate.

CONCLUSION

The average per-person lifetime cost of PID ranges between $1060 and $3180. Future cost-effectiveness analyses of STD screening programs can include this range as a reasonable upper and lower bound. These findings suggest successful PID prevention efforts may avert substantial costs for care providers such as managed care organizations while providing well documented clinical benefits for women in the United States.

Healthcare utilization by women in a comprehensive managed care population subsequent to diagnosis of a sexually transmitted disease

BACKGROUND

Healthcare utilization (HCU) following a sexually transmitted disease (STD) diagnosis is poorly characterized.

GOAL

The goal was to quantify HCU for new/recurrent STDs and other relevant Ob-Gyn and mental health problems in the 18 months subsequent to an STD diagnosis.

STUDY DESIGN

We compared HCU between a group of females aged 18 to 45 years who were Kaiser Permanente Medical Program members with a diagnosed STD (n = 1,205) and a medical center- and age group-matched sample of women seen for a non-STD diagnosis in the same time period (n = 4820), with controlling where appropriate for age, medical center, and chronic disease status.

RESULTS

An STD diagnosis was associated with significantly greater likelihood of subsequent visits for STDs (relative risk [RR] = 3.8), pelvic inflammatory disease/endometritis (RR = 2.9), candidiasis (RR = 2.0), vaginitis (RR = 2.4), cervical dysplasia (RR = 1.7), menstrual disorders/abnormal bleeding (RR = 1.3), high risk/complicated/ectopic pregnancy (RR = 1.5), and behavioral/mental health problems (RR = 1.3) than for women seen for a non-STD diagnosis.

CONCLUSION

Detrimental sequelae of STDs are reflected in substantially elevated near-term HCU following an STD diagnosis.

L12 enhances gonococcal transcytosis of polarized Hec1B cells via the lutropin receptor

We previously reported that gonococci convert to a more invasive phenotype (Inv(+)GC) following contact with cells expressing the lutropin receptor (LHr) and that Inv(+)GC express a novel adhesin that interacts with LHr. We propose that this adhesion allows Inv(+)GC to activate LHr and induce gonococcal transcytosis, usurping normal LHr function in fallopian and endometrial epithelium, which is to transport fetal chorionic gonadotropin (hCG) into the mother. Infected polarized Hec1B monolayers, grown on collagen-coated transwells, showed that the passage of GC across the monolayer occurred rapidly, within 30 min, and proceeded at a constant rate with Inv(+)GC passage three-fold faster than GC grown in tissue culture media alone (Inv(-)GC). Electron microscopy found that Inv(+)GC triggered pseudopod formation around the bacterium, with GC found throughout the Hec1B targets within 30 min, while Inv(-)GC did neither. Pre-treatment of Inv(-)GC with recombinant ribosomal protein L12, a gonococcal "hCG-like" protein previously shown to increase invasion, also increased Inv(-)GC transcytosis to the rate of Inv(+)GC. This enhancement was completely abolished by addition of luteinizing hormone, a cognate ligand of LHr. This is convincing evidence that surface expressed L12 mediates gonococcal invasion and transcytosis via LHr, a mechanism that could be important in the development of invasive gonococcal disease in women.

Prevalence of Chlamydia trachomatis, Chlamydia psittaci and Chlamydia pneumoniae antibodies in blood donors and attendees of STD clinics

OBJECTIVE: To estimate the prevalence of Chlamydia trachomatis, C. psittaci and C. pneumoniae antibodies in sera from altogether 931 blood donors, patients with symptoms of urethritis, assumed salpingitis and sexually acquired reactive arthritis (SARA), and women with fertility problems. METHODS: IgG antibodies to C. trachomatis, C. psittaci and C. pneumoniae were determined by microimmunofluorescence (MIF) tests. All patients were also tested for genital C. trachomatis infection using direct immunofluorescence (DIF) tests. RESULTS: The DIF-positive cases had a significantly (p < 0.0001) higher prevalence of C. trachomatis antibodies than the DIF negatives, i.e. 88.5% versus 14% in men with urethritis, 94.3% versus 36.4% in women with salpingitis, 66.7% versus 16.7% in SARA patients and 90.6% versus 20.8% in women with fertility problems. Antibody reactivity to all three chlamydial species was found significantly (p < 0.0001) more often in the patient groups and in those with a DIF-confirmed genital C. trachomatis infection than in blood donors. CONCLUSIONS: Presence of serum antibodies to C. trachomatis is tightly associated with the presence of chlamydiae in the genital tract, which also influences the cross-reactivities occurring in the MIF tests between chlamydial species.

Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection

BACKGROUND

Chlamydia trachomatis is a frequent cause of pelvic inflammatory disease. However, there is little information from clinical studies about whether screening women for cervical chlamydial infection can reduce the incidence of this serious illness.

METHODS

We conducted a randomized, controlled trial to determine whether selective testing for cervical chlamydial infection prevented pelvic inflammatory disease. Women who were at high risk for disease were identified by means of a questionnaire mailed to all women enrollees in a health maintenance organization who were 18 to 34 years of age. Eligible respondents were randomly assigned to undergo testing for C. trachomatis or to receive usual care; both groups were followed for one year. Possible cases of pelvic inflammatory disease were identified through a variety of data bases and were confirmed by review of the women's medical records. We used an intention-to-screen analysis to compare the incidence of pelvic inflammatory disease in the two groups of women.

RESULTS

Of the 2607 eligible women, 1009 were randomly assigned to screening and 1598 to usual care. A total of 645 women in the screening group (64 percent) for chlamydia; 7 percent tested positive and were treated. At the end of the follow-up period, there had been 9 verified cases of pelvic inflammatory disease among the women in the screening group and 33 cases among the women receiving usual care (relative risk, 0.44; 95 percent confidence interval, 0.20 to 0.90). We found similar results when we used logistic-regression analysis to control for potentially confounding variables.

CONCLUSIONS

A strategy of identifying, testing, and treating women at increased risk for cervical chlamydial infection was associated with a reduced incidence of pelvic inflammatory disease.