Anti-inflammatory mechanism of the optimized active ingredients of Sargentodoxa cuneata and Patrinia villosa

Pelvic inflammatory disease (PID) is a common gynecological infection. The combined use of Sargentodoxa cuneata (da xue teng) and Patrinia villosa (bai jiang cao) has been shown to inhibit PID progression. The active components of S. cuneata (emodin, Emo) and P. villosa (acacetin, Aca; oleanolic acid, OA; sinoacutine, Sin) have been identified but the mode of action of this combination of compounds against PID has not been clarified. Therefore, this study aims to investigate the mechanism of these active components against PID through network pharmacological, molecular docking and experimental validation. The results showed the optimal combination of components was 40 µM Emo + 40 µM OA, 40 µM Emo + 40 µM Aca, and 40 µM Emo + 150 µM Sin by cell proliferation and NO release. The potential key targets of this combination in the treatment of PID include SRC, GRB2, PIK3R1, PIK3CA, PTPN11, and SOS1, which act on signaling pathways such as EGFR, PI3K/Akt, TNF, and IL-17. Emo, Aca, OA, and their optimal combination inhibited the expression of IL-6, TNF-α, MCP-1, IL-12p70, IFN-γ, and the M1 phenotype markers CD11c and CD16/32, and promoted the expression of the M2 phenotype markers CD206 and arginase 1 (Arg1). Western blotting confirmed that Emo, Aca, OA, and their optimal combination significantly inhibited the expression of glucose metabolism-related proteins PKM2, PD, HK I, and HK II. This study proved the advantage of combination use of active components from S. cuneata and P. villosa, and clarified that they exert the anti-inflammatory effect by regulation of M1/M2 phenotype transition and regulation of glucose metabolism. The results provide a theoretical basis for the clinical treatment of PID.

[Pelvic Inflammatory Disease - Synergies between Family Practices and Gynaecological Specialised Assessment]

Pelvic Inflammatory Disease - Synergies between Family Practices and Gynaecological Specialised Assessment Abstract. The 'pelvic inflammatory disease' (PID) describes an ascending inflammation of the upper female genital tract, beginning with a local cervicitis and proceeding to endometritis and adnexitis. It is a common clinical picture with rising numbers in recent years, and it occurs both in gynaecological and general practice. The symptoms are often unspecific, discrete or althogehter lacking. In order to reduce long-term risks of chronic pelvic pain, sterility and/or ectopic pregnancies, rapid diagnosis followed by immediate therapy and a good interdisciplinary cooperation are necessary. Screening programs for chlamydia and gonococcus as the most common pathogens of PID have not yet been implemented in Switzerland so far.

Multidrug-resistant Mycoplasma genitalium infections in Europe

In Japan and Australia, multidrug-resistant Mycoplasma genitalium infections are reported with increasing frequency. Although macrolide-resistant M. genitalium strains are common in Europe and North America, fluoroquinolone-resistant strains are still exceptional. However, an increase of multidrug-resistant M. genitalium in Europe and America is to be expected. The aim of this paper is to increase awareness on the rising number of multidrug-resistant M. genitalium strains. Here, one of the first cases of infection with a genetically proven multidrug-resistant M. genitalium strain in Europe is described. The patient was a native Dutch 47-year-old male patient with urethritis. Mycoplasma genitalium was detected, but treatment failed with azithromycin, doxycycline and moxifloxacin. A urogenital sample was used to determine the sequence of the 23S rRNA, gyrA, gyrB and parC genes. The sample contained an A2059G single nucleotide polymorphism (SNP) in the 23S rRNA gene and an SNP in the parC gene, resulting in an amino acid change of Ser83 → Ile, explaining both azithromycin and moxifloxacin treatment failure. The SNPs associated with resistance were probably generated de novo, as a link with high-prevalence areas was not established. It is, thus, predictable that there is going to be an increase of multidrug-resistant M. genitalium strains in Europe. As treatment options for multidrug-resistant M. genitalium are limited, the treatment of M. genitalium infections needs to be carefully considered in order to limit the rapid increase of resistance to macrolides and fluoroquinolones.

Clinical characteristics of genital chlamydia infection in pelvic inflammatory disease

BACKGROUND

Chlamydia infection in acute pelvic inflammatory disease (PID) is associated with serious complications including ectopic pregnancy, tubal infertility, Fitz-Hugh-Curtis syndrome and tubo-ovarian abscess (TOA). This study compared clinical and laboratory data between PID with and without chlamydia infection.

METHODS

The medical records of 497 women who were admitted with PID between 2002 and 2011 were reviewed. The patients were divided into two groups (PID with and without chlamydia infection), which were compared in terms of the patients' characteristics, clinical presentation, and laboratory findings, including inflammatory markers.

RESULTS

The chlamydia and non-chlamydia groups comprised 175 and 322 women, respectively. The patients in the chlamydia group were younger and had a higher rate of TOA, a longer mean hospital stay, and had undergone more surgeries than the patients in the non- chlamydia group. The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and CA-125 level were higher in the chlamydia group than in the non-chlamydia group, but there was no significant difference in the white blood cell count between the two groups. The CA-125 level was the strongest predictor of chlamydia infection, followed by the ESR and CRP level. The area under the receiving operating curve for CA-125, ESR, and CRP was 0.804, 0.755, and 0.663, respectively.

CONCLUSIONS

Chlamydia infection in acute PID is associated with increased level of inflammatory markers, such as CA-125, ESR and CRP, incidence of TOA, operation risk, and longer hospitalization.

Recruitment of Minority Adolescents and Young Adults into Randomised Clinical Trials: Testing the Design of the Technology Enhanced Community Health Nursing (TECH-N) Pelvic Inflammatory Disease Trial

PURPOSE

Pelvic inflammatory disease (PID) disproportionately affects adolescent and young adult (AYA) women and can negatively influence reproductive health trajectories. Few randomized controlled trials (RCTs) have focused on strategies to improve outpatient adherence or to reduce reproductive morbidity in this population. This paper describes the research methods and preliminary effectiveness of recruitment, retention, and intervention strategies employed in a novel RCT designed to test a technology-enhanced community-health nursing (TECH-N) intervention among urban AYA with PID.

METHODS

AYA women aged 13-25 years were recruited during acute PID visits in outpatient clinics and emergency departments (ED) to participate in this IRB-approved trial. Participants completed an audio-computerized self-interview (ACASI), provided vaginal specimens, and were randomized to standard treatment or the intervention. Intervention participants received text-messaging support for 30 days and a community health nurse (CHN) interventionist performed a home visit with clinical assessment within 5 days after enrollment. All patients received a full course of medications and completed research visits at 14-days (adherence), 30 days and 90 days with by an outreach worker. STI testing performed at the 30-and 90-day visits. Exploratory analyses using descriptive statistics were conducted to examine recruitment, retention, and follow-up data to test the overall design of the intervention.

RESULTS

In the first 48 months, 64% of 463 patients were eligible for the study and 81.2% of 293 eligible patients were recruited for the study (63.3%); 238 (81.2%) of eligible patients were enrolled. Most participants were African American (95.6%) with a mean age of 18.6 (2.3). Ninety-four percent of individuals assigned to the TECH-N intervention completed the nursing visits. All completed visits have been within the 5-day window and over 90% of patients in both arms have been retained over the 3-month follow-up period. Biological data suggests a shift in the biological milieu with the predominance of Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis infections.

CONCLUSIONS

Preliminary data from the TECH-N study demonstrated that urban, low-income, minority AYA with PID can effectively be recruited and retained to participate in sexual and reproductive health RCTs with sufficient investment in the design and infrastructure of the study. Community-based sexual health interventions appear to be both feasible and acceptable in this population.

Cross-sectional analysis of Toll-like receptor variants and bacterial vaginosis in African-American women with pelvic inflammatory disease

OBJECTIVE

Bacterial vaginosis (BV) is a common condition associated with serious complications including pelvic inflammatory disease (PID). However, the pathogenesis of BV is poorly understood. Toll-like receptors (TLR) are responsible for microbial recognition and elimination through inflammatory responses. TLR variants have been implicated in infectious and inflammatory diseases and may be involved in BV pathogenesis. We conducted a cross-sectional study to determine if TLR variants are associated with BV.

METHODS

Logistic regression was used to test associations between 14 variants assayed in 6 genes (TLR1, TLR2, TLR4, TLR6, TIRAP and MyD88) and BV/intermediate flora among 192 African-American women with clinical PID from the PID Evaluation and Clinical Health (PEACH) Study. Additionally, we examined associations between variants and endometrial BV-associated anaerobes. To account for multiple comparisons a permutated p<0.003 was used to determine statistical significance.

RESULTS

African-American women with PID carrying the AA genotype for TLR2 SNP rs1898830 had a threefold increased rate of BV/intermediate flora (OR 2.9, 95% CI 1.2 to 7.3). This was not significant after accounting for multiple comparisons (p=0.0201). TLR2 variants rs1898830, rs11938228 and rs3804099 were associated with increased endometrial anaerobic gram-negative rods (p=0.0107, p=0.0076 p=0.0121), anaerobic non-pigmented Gram-negative rods (p=0.0231, p=0.0083, p=0.0044), and anaerobic Gram-positive cocci (p=0.0596, p=0.0640, p=0.1459).

CONCLUSIONS

Among African-American women with PID, we observed trends between TLR2 variants, BV/intermediate flora, and BV-associated microbes. This provides some insight into BV pathogenesis. As not all BV-associated microbes may lead to pathology, future studies should focus on associations between TLR variants and individual BV-associated microbes.

Contraceptive choice, sexually transmitted diseases, HIV infection, and future fecundity

Because contraception affects not only the risk of unplanned pregnancy but also that of sexually transmitted infections, the choice of particular methods is important to future fertility. However, certain trade-offs are necessary. Contraceptives with the best record of preventing pregnancy provide little protection against sexually transmitted diseases (STDs). Conversely, those barrier methods with higher failure rates for pregnancy can reduce the risk of acquiring or transmitting an STD. For example, condoms used correctly and consistently provide the best protection against infection. Although spermicides reduce lower genital tract bacterial STDs, their effectiveness against HIV is still unknown. In contrast to barrier methods, the IUD is associated with an increased risk for developing upper genital tract infection, primarily in the first month after insertion. Current literature raises paradoxical questions regarding the role of hormonal contraception in STDs and pelvic inflammatory disease. Moreover, epidemiological studies are equivocal regarding the public health value of recommending dual methods of contraception, one to prevent unplanned pregnancy and the other to prevent STDs. Investigations to date have focused on the use of the male condom added to other methods of contraception. In general, where participants were using primary methods other than the condom, the more effective the primary contraceptive method was in preventing pregnancy, the lower the level of consistent use of the male condom. Continued biologic and behavioral research will be necessary to disentangle these complex relationships.

The incidence of actinomyces-like organisms in Papanicolaou-stained smears of copper- and levonorgestrel-releasing intrauterine devices

Actinomyces-like organisms (ALOs) are a common finding in Papanicolaou-stained cervico-vaginal smears (PAP smears) of women using an intrauterine device (IUD). The incidence of ALOs positive PAP smears depends on the type of IUD. Pelvic actinomycosis is a severe disease that may require hysterectomy and salpingo-oophorectomy. In a retrospective study we compared the incidence of ALOs positive PAP smears in users of the new levonorgestrel-releasing intrauterine device (LNG-IUD) (n = 52) with the incidence in Multiload Copper IUD (ML375) users (n = 104). All IUDs had been inserted from 1996-1998. Women with a follow-up period of more than 9 months were included into the final analysis (LNG-IUD: n = 34; ML375: n = 65). The incidence of ALOs in LNG-IUD users (2.9%) was significantly lower than in ML375 users (20%). Clinical consequences of ALOs positive PAP smears are discussed controversially. The low incidence in the LNG-IUD users probably leads to less IUD-removals, reinsertions and less pelvic-inflammatory-diseases.

Is it evidence-based practice? Prophylactic antibiotics for termination of pregnancy to minimize post-abortion pelvic infection?

Sexually transmitted infections (STIs) causing upper genital tract problems after termination of pregnancy (TOP) is well recognized. We undertook this study to assess the local prevalence of Chlamydia trachomatis infection and to estimate the potential benefits of introducing screening. The prevalence rate of C. trachomatis was 6%. Nine sexual contacts of the index cases were identified. They were symptom free, but all had non-specific urethritis (NSU). Four of them were positive for C. trachomatis. We conclude that screening for chlamydial infection is essential and routine prophylactic antibiotic cover may not be beneficial.

Prophylactic antibiotics for intrauterine device insertion: a metaanalysis of the randomized controlled trials

We evaluated the effectiveness of prophylactic antibiotic administration before IUD insertion in reducing the incidence of pelvic inflammatory disease, unscheduled visits back to the clinician, and IUD discontinuations within 3 months of insertion. We performed a metaanalysis of all known randomized controlled trials comparing an antibiotic (either oral doxycycline or azithromycin) versus a placebo or no treatment. Use of prophylaxis significantly reduced the frequency of unscheduled return visits (odds ratio 0.82; 95% CI 0.70, 0.98). The protection against pelvic inflammatory disease was smaller and not statistically significant 0.89 (95% CI 0.53, 1.51). No significant effect on premature IUD discontinuation was evident. Use of either doxycycline or azithromycin before IUD insertion offered little observable benefit in the US. Prophylaxis reduced unscheduled visits and possibly PID in developing countries, which have higher rates of sexually transmitted diseases than in the US. A more important finding in these trials is the low incidence of pelvic inflammatory disease with or without prophylactic antibiotics.

The availability and cost of antibiotics for treating PID in the Central Region of Ghana and implications for compliance with national treatment guidelines

The availability and cost of antibiotics for treating pelvic inflammatory disease (PID) were assessed in 17 drug-dispensing outlets in 5 districts of the Central Region, Ghana. The outlets included the dispensaries of 2 regional and 4 district hospitals, 4 privately-owned pharmacies and 7 chemical seller shops. The most common antibiotics available, including co-trimoxazole, metronidazole, benzylpenicillin, amoxycillin, chloramphenicol and gentamicin, were also the lowest-priced drugs. Conversely, the most expensive antibiotics including ceftriaxone, ciprofloxacin, cefuroxime and spectinomycin, were also the least commonly available. Recommended anti-gonococcal antibiotics (ciprofloxacin, ceftriaxone) may not be prescribed if they are not available in the districts.

Reproductive tract infections, gynaecological morbidity and HIV seroprevalence among women in Mumbai, India

Reported are the prevalence of reproductive tract infections and their contribution to pelvic inflammatory disease (PID), as well as the seroprevalence of human immunodeficiency virus (HIV), among women living in three inner city wards of Mumbai, India. Women aged < or = 35 years were recruited and screened as cases if they had been admitted to hospital for gynaecological investigation for suspected PID (n = 151) or infertility (n = 295); controls were healthy fertile women attending for laparoscopic tubal ligation (n = 2433). The women were mainly of low socioeconomic status. A total of 59.4% were migrants and 14.9% of these came to Mumbai to seek treatment. Cases reported a history of adverse pregnancy outcomes significantly more often than controls, and 30.5% of suspected PID cases had previously undergone laparoscopic tubal ligation. At examination 24.2% of cases and 8.4% of controls had a vaginal discharge. Pelvic infection was confirmed in 42.0% of suspected PID cases and 14.6% of infertile cases for whom diagnostic laparoscopy was performed. The prevalence of sexually transmitted diseases was low: Chlamydia trachomatis was found in 0.2%; and Neisseria gonorrhoeae was cultured from the cervix in only four cases. Neither of these infections was detected in laparoscopic aspirates. The prevalence of HIV1/2 infections in unlinked samples was 1.9%. Sexually transmitted diseases were not major factors leading to gynaecological morbidity. Heterosexual spread of HIV infection to this population of married women is still relatively low but needs to be carefully monitored. The gynaecological morbidity detected may be a consequence of widespread use of invasive methods of fertility regulation.

Gynecology and family planning care for the woman infected with HIV

This article reviews the interactions between HIV infection and a variety of gynecologic conditions, including lower genital tract neoplasia, pelvic inflammatory disease, menstrual disorders, sexually transmitted diseases, and vaginitis. Important considerations in choosing a family planning method for women infected with HIV-infected women will respond to standard therapy, but require multiple courses of treatment or use of innovative treatment methods. All HIV-infected women deserve careful evaluation for and treatment of gynecologic diseases.

[The urological complications of contraception using intrauterine coils]

Being a foreign body, intrauterine coil causes decubitus and inflammation of the adjacent tissues. Long-term carriage of the coil may give rise to endometritis, myometritis, parametritis, salpingo-oophoritis, tubo-ovarian inflammatory infiltrates. These infiltrates invade retroperitoneal pelvic fat and may obstruct pelvic ureters. Ureteral obstruction may bring about ureterohydronephrosis, pyelonephritis and renal calculi. The coil may be also responsible for chronic pyelonephritis. The authors have treated 64 females aged 18-45 years with urological complications due to intrauterine coils which stayed from 6 months to 14 years. 34 of them presented with attack of acute pyelonephritis, 29 with renal colic and acute pyelonephritis, 26 with renal calculi. To arrest renal colic and attack of acute pyelonephritis ureteral catheterization and renal pelvis drain were performed in 31 patients. One patient has undergone ureterolithotomy. 8 patients rejected removal of the coil and had recurrent renal colics and acute pyelonephritis attacks. Removal of the coil arrested pyelonephritis and lithogenesis in the kidney. In one case of coil removal there was injury to the uterine cervix and urinary bladder eventuating in vesicovaginal fistula.

Intrauterine contraception in adolescent women. The GyneFix intrauterine implant

Pregnancy rates among adolescents have not decreased over the last 10 years, despite numerous efforts. To solve this important health problem, the major strategy recommended is to encourage contraceptive use among sexually active teenagers. An important means of obtaining this is by promoting methods that are not dependent on daily administration in order to avoid noncompliance. One such method (Norplant) has already shown to be much more effective than the combination pill in preventing pregnancy in adolescent women. The frameless intrauterine implant system (fixed, frameless, and completely flexible) has been studied since 1985 in women between 14 and 50 years of age. The results in young nulligravid women confirm its very high effectiveness (cumulative pregnancy rate at 36 months: 1.4%), its low expulsion rate (cumulative rate at 36 months: 0.9%) and its optimal tolerance (cumulative removal rate for medical reasons at 36 months: 2.4%), resulting in a high acceptance of the implant and a high continued use. The system (GyneFix) offers long-term protection (5 years), and its insertion, with or without anesthetic, is easily accomplished in the office. The GyneFix should therefore be recommended as an excellent alternative for birth control pills for young women with low risk for STDs, especially when compliance is a problem, without an increased risk for complications and without systemic side effects. Removal of the device is accomplished by traction on the tail. It can also be used for emergency contraception and for insertion immediately after termination of pregnancy.

Pelvic inflammatory disease in patients with bilateral tubal ligation

Classic teaching has stated that women who have undergone bilateral tubal ligation (BTL) are not susceptible to pelvic inflammatory disease (PID). The purpose of this study was to confirm the existence of PID in patients with BTL and to compare clinical parameters of these patients with PID patients who have not had BTL. A retrospective chart review of emergency department (ED) patients diagnosed with PID over a 1-year period at a large urban university hospital found 209 patients who fulfilled the criteria for a definition of PID. Of the 209 patients with PID, 24 (11.7%) had undergone BTL. Patients with and without BTL were compared with respect to age, white blood cell count (WBC), temperature, admission rate, length of hospitalization, prior history of PID, culture results, presence of bilateral abdominal pain, presence of rebound tenderness, and complications of tubo-ovarian abscess (TOA) and hydrosalpinx. Patients with BTL had lower WBCs (11,100/microL v14,700/microL) and were 2.5 times less likely to be hospitalized compared to those patients without BTL. These results show that PID in the setting of a prior BTL not only exists but occurs with surprising frequency and deserves further study. Patients with BTL and PID may have a clinically milder form of PID than those patients without BTL.

Oral contraception and the recognition of endometritis

OBJECTIVE

Oral contraceptive use has been associated with a lower risk of symptomatic pelvic inflammatory disease but a higher risk of chlamydial cervicitis. To explain these seemingly contradictory findings, we asked whether oral contraceptive use was more common among women with unrecognized endometritis than among women with recognized endometritis.

STUDY DESIGN

A multicenter case-control study was performed. Women without signs of pelvic inflammatory disease were ascertained through contact tracing of partners with sexually transmitted diseases or through presentation with cervicitis. Women with symptomatic pelvic inflammatory disease met a set of standard clinical criteria. We compared the 43 cases without signs of pelvic inflammatory disease but with endometritis ("unrecognized endometritis") with the 111 controls with recognized pelvic inflammatory disease and endometritis ("recognized endometritis").

RESULTS

Women with unrecognized endometritis were 4.3 times (95% confidence interval 1.6 to 11.7) more likely than women with recognized endometritis to use oral contraceptives.

CONCLUSION

Future studies need to fully characterize the risks and benefits of oral contraceptives in relation to sexually transmitted diseases.

HIV and reproductive tract infections in a total village population in rural Kilimanjaro, Tanzania: women at increased risk

The aim of this study was to determine the prevalence of HIV infection, other sexually transmitted diseases (STDs), and biological risk factors associated with HIV infection in a rural population in Tanzania. A population-based study of a village population was carried out from July 1991 through January 1992. A total of 3,239 people (83.7%) participated in an HIV serosurvey. The total HIV prevalence was 0.7 and 1.9% among males and females, respectively (odds ratio, OR = 2.5; 95% confidence interval, CI: 1.2-5.1), and 4.3% in women and 1.6% in men in participants aged 15 to 44 (OR = 2.6; CI: 1.2-5.8). The same age group was interviewed and offered screening for STDs. Trichomonas vaginalis vaginitis (24.7%) was the most common reproductive tract infection (RTI); 10.3% of women were infertile and 10.6% suffered from pelvic inflammatory disease (PID). Comparing women and men, we found that 2.2 versus 20.4% had been treated for genital discharge (OR = 12.6; CI: 7.1-22.5); 2.6 versus 1.2% suffered from active syphilis (OR = 1.5; CI: 0.9-2.3); 6.9 versus 9.6% had chlamydial infection; and 46.9 versus 14.6% had an ongoing RTI/STD (OR = 5.0; CI: 3.6-6.9). A significant association was found between HIV infection and STD cases (in women) and between HIV infection and a history of STDs (in men). The heavy burden of untreated RTIs in females calls for a more gender-specific approach to HIV and STD prevention.

IUD users in Norway are at low risk for genital C. trachomatis infection

From May 1993 to April 1995, 30 general practitioners located at 13 general practice settings in the city of Trondheim, central Norway, recruited 957 eligible participants in a prospective use-effectiveness study on performance of two copper IUDs. In this report we focus on screening for C. trachomatis at insertion and its possible effect on cause-related terminations during the first 90 days after insertion. All women were screened at IUD insertion for C. trachomatis. All specimens were analyzed applying a nucleic acid test (rRNA, GenProbe). Five out of 957 women (0.5%) were positive for C. trachomatis. All were treated within two weeks of diagnosis. No cases of pelvic inflammatory disease were diagnosed during the first three months of the study. Screening of C. trachomatis at IUD insertion is not recommended in Norwegian women because of the extremely low prevalence of C. trachomatis in those who choose IUD as their primary contraceptive method. Recommendations for universally screening women for sexually transmitted diseases at IUD insertion should be based upon review of local/national prevalence data.

The impact of oral contraception on chlamydial infection among patients with pelvic inflammatory disease

The prevalence of oral contraceptive use in association with chlamydial pelvic inflammatory disease (PID) and the presence of anti-chlamydial IgG and IgA in a population of 144 hospitalized and outpatient subjects with a standard diagnosis of PID was studied. The rates of chlamydial PID and IgA detection were 15.3% (22/144) and 13.9% (20/144), respectively. After stratification for age, number of pregnancies, and lifetime sexual partners, the rates of chlamydial PID (odds ratio = 0.30, 95% CI = 0.10 - 0.89) and IgA detection (odds ratio = 0.23, 95% CI = 0.07 - 0.73) were lower among previous or current oral contraceptive users than in women who had never used birth control methods. Analyses of linear trend indicated a negative association between increasing duration of exposure to hormonal contraception and anti-chlamydial IgG and IgA. This study confirms that among patients with chlamydial PID, the frequency of oral contraceptive use is lower than that in patients with PID of other etiology. Serologic studies suggest a possible relationship between hormonal contraception and changes in immune response or susceptibility to chlamydial infection.

Anaerobic and aerobic microflora of pouch of Douglas aspirate v/s high vaginal swab in cases of pelvic inflammatory disease

The anaerobic and aerobic bacterial flora in pouch of Douglas (POD) aspirate and high vaginal swabs (HVS) was studied in 43 cases of pelvic inflammatory disease (PID) using standard techniques. High vaginal swabs from 20 healthy women were included as controls. Anaerobic and aerobic bacteria were isolated from 37 (86%) HVS and 31 (72%) POD aspirates from these 43 women. A total of 100 aerobic and 10 anaerobic bacterial strains were recovered from both the sites. Coagulase negative staphylococci (28), Escherichia coli (23) and Streptococcus faecalis (14) were predominant aerobic bacteria. Of the anaerobes, peptostreptococci species and Bacteroides species were more common, polymicrobial flora (more than one type of organism) was present in a total of 27 specimens. However mixture of anaerobic and aerobic bacteria were seen in only 5 specimens. Of the 20 control specimens, ten were positive for organisms. Ten aerobic and 3 anaerobic bacterial strains were recovered.

Evidence against tailstrings increasing the rate of pelvic inflammatory disease among IUD users

A meta-analysis was conducted to determine whether the presence of an IUD tailstring is associated with increased rates of pelvic inflammatory disease among IUD users. Included were seven clinical studies that compared the same IUD with and without a tail, and fifteen clinical studies that compared two similar copper IUDs that differed in the polymer used for the tailstring (polypropylene versus polyethylene). No increase in PID rates was found among users of IUDs with versus without a tail (RR = 1.2, 95% confidence interval 0.6-1.7), or among users of copper IUDs with different tailstring materials (polypropylene vs. polyethylene, RR = 0.9, 95% confidence interval 0.4-1.5). These findings support the hypothesis that the presence of a tailstring does not increase the rate of PID among users of IUDs.

Chlamydial infection in a population of Ethiopian women attending obstetric, gynaecological and mother and child health clinics

The prevalence of chlamydial infection was assessed in 1,846 Ethiopian women attending clinics in Addis Ababa. Sera were tested for type-specific anti-chlamydial antibodies using purified chlamydial antigens (C. trachomatis A-C (CTA-C), C. trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGVI-3), and C. pneumoniae (CPn), in a micro-immunofluorescence (micro-IF) test. Three levels of chlamydial infection were established. Sera with: 1) antibodies to CTA-C, CTD-K, LGV 1-3 and CPn singly or in combination, are considered as evidence of overall exposure to chlamydial species (OEC); 2) antibodies to CTD-K and LGV 1-3 are considered as evidence of exposure to genital chlamydial pathogens (GENCI); 3) IgM titre > or = 1/8, or Ig G titre > or = 1/64 to CTD-K and LGV 1-3 alone or at a similar level with antibodies to CTA-C and CPn is considered as being evidence of active genital chlamydial infection (AGCI). OEC was found in 84 pc, GENCI in 60 pc and AGCI in 42 pc. Infection was highest in family planning and lowest in antenatal clinic attenders. OEC increased progressively with age while GENCI and AGCI peaked at ages 35 to 49. Chlamydial infection was highest in those married and sexually active < 13 years of age (OEC 88 pc, GENCI 69 pc, AGCI 49 pc); the lowest income groups (OEC 85 pc, GENCI 65 pc, AGCI 45 pc); those with more than five sexual partners (OEC 92 pc, GENCI 78 pc and AGCI 65 pc); with highest prevalence in bargirls (OEC 97 pc, GENCI 84 pc, AGCI 75 pc). Fifty pc had clinical evidence of past or present infection in the urethra, salpinges or bartholin glands (USB). OEC, GENCI and AGCI were associated with PID. The association of seropositivity with USB was remarkably similar for both gonorrhoea and chlamydial infection: we recommend adoption of a treatment regimen effective for both infections. The micro-IF test is a useful epidemiological tool for identifying the of antibodies to chlamydial pathogens. Use of antigen pools CTA-C, CTD-K LGVI-3 and CPn enables a distinction to be made between genital and non-genital infections. The problem of symptomatic and asymptomatic chlamydial disease needs to be addressed urgently.

Effect of pelvic inflammatory disease on fertility

Genital infections, in both men and women, may cause permanent functional damage to the reproductive tract resulting in infertility. In men, post-infection infertility is uncommon, whereas in women sequelae after pelvic inflammatory disease (PID) are the most common cause of acquired infertility. In a prospective cohort study of women who all sought pregnancy after laparoscopically verified acute (non-tuberculous) salpingitis, 141/1309 (10.8%) were infertile because of proven post-PID tubal occlusion. In 448 control women, the corresponding figures were 4/448 (0.9%). Of independent and significant importance for post-PID infertility were the numbers of PID episodes (0/1/2 or= 3: RRs 1.0/7.0/16.2/28.3), and in women with only one PID episode, the severity of infection (mild/moderate/severe; RRs 1/1.8/5.6), delayed care (3 days/3 or more days; RR 1/2.8), use of contraceptives (none/pills/IUDs/other; RRs 1/0.3/0.5/0.8). Similar influences of the same variables were also demonstrated for subfertility, i.e. ectopic pregnancy, and time between index laparoscopy and pregnancy in those women who conceived after PID.

Reproductive potential after an ectopic pregnancy

OBJECTIVE

To measure statistically how soon pregnancy can occur after an ectopic pregnancy (EP) so as to determine the cumulative pregnancy rate and the risk factors involved in nonpregnancy.

DESIGN

The risk of not getting pregnant after an EP (survivorship) was estimated for 120 patients followed up for up to 60 months using the actuarial life-table technique. The risk factors involved in nonpregnancy, abortions, or live births were analyzed, using Cox regression models.

SETTING

King Khalid University Hospital, Riyadh, Saudi Arabia.

RESULTS

There were 68 pregnancies over the study period, with a conception rate of 56.7%. Using the actuarial life table, the cumulative probability of not achieving pregnancy in a patient decreased sharply during the first 12 months, followed by a gradual decrease up to 48 months. The Cox regression analysis showed a correlation between pregnancy and two variables, namely, age and history of prior EP. The chances of a pregnancy resulting in abortion or live birth also correlated with the presence of prior infertility, pelvic inflammatory disease (PID), or postoperative complications.

CONCLUSION

Age and prior EP are important determinants in pregnancy rates after an EP. Similarly, history of PID, infertility, and postoperative complications are important risk factors in whether the pregnancy goes to term or ends in abortion.

Self-reported symptoms of gynecological morbidity and their treatment in south India

This article presents an analysis of self-reported symptoms of gynecological problems among 3,600 recent mothers in Karnataka State, India. Approximately one-third of all women reported at least one current symptom; the most common were a feeling of weakness and tiredness (suggestive of anemia); menstrual disorders; white or colored vaginal discharge (suggestive of lower reproductive tract infection); and lower abdominal pain and discharge with fever (suggestive of acute pelvic inflammatory disease). Obstetric morbidity, associated with the last live birth, was strongly predictive of current gynecological symptoms. Women who delivered their last child in a private institution were significantly less likely to report symptoms than were those who delivered at home or in a government hospital. Nonusers or users of reversible contraceptive methods were also less likely to report symptoms of morbid conditions than were sterilized women. These associations persisted in analyses controlling for potentially confounding economic and demographic characteristics, and have far-reaching policy implications.

Ultrasonographically guided transvaginal aspiration of tuboovarian abscesses and pyosalpinges: an optional treatment for acute pelvic inflammatory disease

OBJECTIVE

Our purpose was to assess the value of ultrasonographically guided transvaginal aspiration of tuboovarian abscesses and pyosalpinges presenting with the clinical picture of acute pelvic inflammatory disease.

STUDY DESIGN

Fifteen patients seen for acute pelvic inflammatory disease were treated by ultrasonographically guided transvaginal aspiration of pus from tuboovarian abscesses and pyosalpinges, followed by local and systemic administration of antimicrobal therapy.

RESULTS

Improvement of symptoms followed aspiration in all patients. Temperature dropped to normal within 24 to 72 hours, and pain completely disappeared within 3 days. All patients were symptom free during a follow-up period of 6 months after aspiration.

CONCLUSION

Ultrasonographically guided transvaginal aspiration of pyosalpinges and tuboovarian abscesses is an effective, simple, and safe treatment. It avoided the need for laparoscopy or laparotomy.

Chlamydia trachomatis in pelvic inflammatory disease

The prevalence of genital Chlamydia trachomatis infection and some epidemiologic factors associated with it were studied in 273 pelvic inflammatory disease (PID) patients attending Gynaecologic clinic, Government Medical College, Nagpur. For detection of chlamydial antigen Pharmacia Diagnostics Chlamydia EIA test was used. This study revealed an overall positivity rate of 33% for C. trachomatis infection in PID patients. Of the hypothesised risk factors low socioeconomic status, history of sexual contacts with multiple partners and use of intrauterine devices (IUD) were significantly associated with C. trachomatis infections. However, use of oral contraceptives, barrier contraceptives and increasing age were found to be protective factors for C. trachomatis infection. Thus considering the significant contribution of C. trachomatis in etiology of PID and its independent association with some epidemiologic risk factors, extensive epidemiologic measures are recommended for prevention of these infections.

Performances of copper T 380A and multiload copper 375/250 intrauterine contraceptive devices in a comparative clinical trial

An evaluation of the performances of copper T 380A (TCU 380A) and multiload copper 375/250 (MLCU 375/250) intrauterine contraceptive devices (IUCDS) was carried out at University College Hospital, Ibadan, Nigeria (UCH) in a clinical comparative trial. The IUCDS showed similar low vent rates at one year of continuous use. The difference in cumulative net probabilities for termination due to pelvic inflammatory disease was weakly significant at the sixth month of follow up with MLCU 250 having the highest rate. (TCU 380A-0%; MLCU 375-0%; MLCU 250-3.1%; X2 = 6.0; P < 0.05). This significant difference disappeared by the twelfth month of continuous use. Likewise, the difference in cumulative net probabilities for overall termination was significant at six months and insignificant at twelve months of follow up. The continuation rate after one year were 86%, 92% and 87% respectively for TCU 380A, MLCU 375 and MLCU 250. These rates were higher than 80% and 51% quoted for the previously available Lippes loop in the same environment [1,2]. It was therefore concluded that the three IUCDS are comparable in performances in the first year of use and could be used at our family planning clinic or any other clinic in a similar setting.

Chest wall actinomycosis in association with the use of an intra-uterine device

A 31 year old woman presented with a chest wall abscess due to Actinomyces israellii and Porphyromonas asaccharolytica (previously Bacteroides asaccharolyticus). She was a long-term user of an intra-uterine device (IUD) and, although asymptomatic, had radiological evidence of pelvic infection. Actinomyces-like organisms were seen on cervico-vaginal smears. The abscess was surgically drained, the IUD removed, and a prolonged course of amoxycillin/clavulanic acid given.

Teenage obstetric and gynaecological problems in an African city

OBJECTIVE

To measure the prevalence of sexually transmitted diseases (STD), pelvic inflammatory disease (PID), cervical cancer, pregnancy and use of contraception in teenagers, and to determine socioeconomic factors associated with these conditions to aid planners of medical services and promotion of sexual health.

SUBJECTS

181 Ethiopian teenagers and 1,845 women aged 20 to 45 years for comparison.

SETTING

Gynaecological outpatient department, antenatal, postnatal and family planning clinics, in two teaching hospitals and a mother and child heath centre in Addis Ababa, Ethiopia.

METHODS

Results of serologic tests for STD, clinical evidence of PID, and cervical cytology were analysed against socio-economic factors.

RESULTS

In teenagers early age at first marriage/coitus, more common in those of rural origin, was associated with poverty, a greater number of lifetime sexual partners, and prostitution: 40 pc were first sexually active before the menarche. Prevalence of seropositivity to specific STD pathogens was; Treponema pallidum (TPHA) 21 pc, Neisseria gonorrhoeae (gonococcal antibody test: GAT) 40 pc, genital chlamydiae 51 pc, hepatitis B virus 36 pc, herpes simplex virus (HSV-2) 32 pc, and Haemophilus ducreyi 16 pc: 92 pc of teenagers were seropositive to one or more STD's. STD seroprevalence was higher in those with more than one sexual partner, those sexually active by age 15 (very high in those sexually active by age 12), those involved in prostitution and those attending the family planning clinic. Forty three pc had clinical evidence of PID; one married at age 10 had invasive cervical cancer by age 18; 40 pc of teenagers were pregnant compared with 25 pc of those aged 20 to 45; 21 pc attended for family planning; of regular FPC attenders 81 pc were GAT seropositive.

CONCLUSION

Despite legislation early age of sexual debut is common, STD and PID are widely prevalent, the pregnancy rate in adolescents is high and contributes to the national population growth rate. Action is required at family, medical and governmental level to encourage cultural acceptance that marriage and sexual activity should not occur before the age of 16 years, with education appropriate to culture to prevent STD. Similar studies are recommended in other countries to establish a baseline for informed strategy regarding prevention of STD and health education.

A reanalysis of the Cu-7 intrauterine contraceptive device clinical trial and the incidence of pelvic inflammatory disease: a paradigm for assessing intrauterine contraceptive device safety

OBJECTIVE

We calculated and compared the incidence of pelvic inflammatory disease in a 10% random sample of the Cu-7 intrauterine contraceptive device (G.D. Searle & Co., Skokie, Ill.) clinical trial with the rates reported to the Food and Drug Administration and those in subsequent trials published in the world literature.

STUDY DESIGN

A 10% random sample of the Cu-7 clinical trial was examined because calculations had demonstrated this random sample to be sufficient in size (n = 1614) to detect a difference in rates of pelvic inflammatory disease from those reported to the Food and Drug Administration. An audit of a subset of the patient files, compared with the original files in Skokie, Illinois, confirmed that the files available for analysis were complete. Standard definitions were used to identify cases of pelvic inflammatory disease and to calculate rates of pelvic inflammatory disease. The world literature on Cu-7 clinical trials was reviewed.

RESULTS

The calculated crude and Pearl index rates of pelvic inflammatory disease were consistent with those rates previously reported to the Food and Drug Administration and published in the medical literature. Life-table pelvic inflammatory disease rates were not different between nulliparous and parous women and pelvic inflammatory disease did not differ from basal annual rates in fecund women.

CONCLUSION

On the basis of the analysis of this 10% sample, the pelvic inflammatory disease patient rates reported to the Food and Drug Administration for the entire Cu-7 clinical trial are accurate and are similar to those published in the world literature.

Transcervical recanalization of strictures in the postoperative fallopian tube

PURPOSE

To evaluate use of transcervical recanalization in patients with reocclusion of the proximal fallopian tube after failed surgery to reverse sterilization or failed tuboplasty to treat inflammatory disease.

MATERIALS AND METHODS

The standard technique for transcervical recanalization was attempted in seven patients after failed reversal surgery and in 12 after failed tuboplasty. Four of seven patients with failed reversal surgery had fistular tracts and one also had a stricture; the remaining three patients and all 12 patients treated after failed tuboplasty and tube reimplantation had strictures at the site of implantation or anastomosis.

RESULTS

Transcervical recanalization failed in all patients with fistulas but succeeded in 13 of 15 with stenoses. Three patients became pregnant 1-16 months after recanalization and two after in vitro fertilization and embryo transfer. Reocclusion occurred in two of 10 patients reexamined 6-36 months after recanalization.

CONCLUSION

Transcervical recanalization is recommended as an alternative to repeat microsurgical reimplantation or tuboplasty.

The intrauterine device in the present and future

Good counseling and better selection of candidates would result in the intrauterine device's (IUD) safer use. Age and parity of the IUD acceptor do not seem to be associated with an increased risk of pelvic inflammatory disease (PID). The newer generation of copper- and hormone-releasing IUDs are associated with improved safety and efficacy.

Acute pelvic infection following hysterosalpingography at the Kenyatta National Hospital, Nairobi

A total of 150 women who had hysterosalpingography (HSG) for investigation of infertility, at the Kenyatta National Hospital over a five month period, were recruited into the study to determine the prevalence of pelvic infection following the procedure. 44.0% of the total study group developed pelvic infection disease (PID) within the first week after the procedure. There were no obvious determining factors. It is possible that most women with infertility have quiescent genital tract infection, prior to HSG, with the latter only facilitating the entry of micro-organisms into the upper genital tract, thus causing pelvic infection or reactivating a pre-existing infections. Further studies should be conducted to determine the microbial patterns of the infection. There should be routine provision of prophylactic antimicrobial agent(s) to all women undergoing HSG in our unit to minimise the risk of developing pelvic infection and further damage to the uterine tubes which will worsen the prognosis.

Three consecutive recurrent ectopic pregnancies

A case of three consecutive repeated ectopic pregnancies is presented in a 36-year-old woman who was being managed for infertility. The first two ectopic pregnancies occurred in the right fallopian tube, and both were treated conservatively. All three ectopic pregnancies were confirmed histopathologically. The aetiology, symptoms and management of the case are discussed, and the literature is reviewed.