[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.

[CME Sonography 91: Differential Diagnosis of Lower Abdominal Pain]

CME Sonography 91: Differential Diagnosis of Lower Abdominal Pain Abstract. Pain in the lower abdomen is a frequent reason for further imaging clarification by sonography. The most frequent causes are appendicitis and diverticulitis, in addition to ureteral stones, ovarian and tubal pathology as well as various hernias. Appendicitis has a characteristic clinical presentation and can be diagnosed by CT or ultrasound. In children, the differential diagnosis is that of mesenteric lymphadenitis. Diverticulitis, often right-sided, can also be reliably diagnosed with CT or ultrasound. Not to be forgotten is the left-sided diverticulitis, which occurs more frequently in Asian persons. Appendicitis epiploica should be recognized to avoid unnecessary operations. The iliopsoas syndrome, which is diagnosed by sonopalpation, often remains undetected.

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.

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.

HIV infection among patients with acute pelvic inflammatory disease at the Kenyatta National Hospital, Nairobi, Kenya

AIDS continues to exert considerable strain on the economy, as well as social aspects of our lives. Previous studies have identified the categories of people most at risk of contracting and developing HIV infection and AIDS. In this study, 20.9% of women with acute pelvic infection at the Kenyatta National Hospital, were found to be seropositive for HIV, much higher than the general population in Kenya. Though there was no direct correlation between one's age and serological status, most of the women with pelvic inflammatory disease (PID) were young, quite sexually active, and involved with several partners. 49.0% of the entire group and 53.7% of the women who were seropositive, were married. This underlines the fact that marital status does not appear to offer any protection against HIV infection. The fact that majority of these women had started coitus quite early, they were not using any protective measure against STDs or HIV infection, and that they were involved with several partners, indicate that we are very far from winning the fight against HIV infection and AIDS. There is need to revise the currently operative programmes with a view to making them more effective, in preventing transmission and spread of HIV infection.

Health gains from screening for infection of the lower genital tract in women attending for termination of pregnancy

Infection of the upper genital tract after abortion is well recognised, but routine screening for infection before termination is rare, and few centres are aware of the prevalence of post-abortion complications in their population. We undertook a study to assess the prevalence and sequelae of genital-tract infection in patients undergoing termination of pregnancy and to estimate the costs and potential benefits of introducing screening and prophylaxis for the most commonly found organisms. The study in Swansea, UK, was of 401 consecutive patients attending for termination of pregnancy; only 1 patient refused to take part. Immediately before the termination procedure vaginal and cervical swabs were taken for microscopic examination and culture of Trichomonas vaginalis, Neisseria gonorrhoeae, and candida species. We sought Chlamydia trachomatis by enzyme-linked immunosorbent assay. 112 (28%) women had the typical bacterial flora of anaerobic (bacterial) vaginosis, 95 (24%) had candidal infection, 32 (8%) chlamydial infection, 3 (0.75%) trichomonas infection, and 1 (0.25%) gonorrhoea. Postoperative follow-up of 30 of the women with chlamydial infection showed that pelvic infection developed in 19 (63%), of whom 7 were readmitted to hospital. 9 male partners of women with chlamydial (plus gonococcal in 1 case) infection were examined; 8 were symptom-free, 3 had C trachomatis infection, and 1 N gonorrhoeae. Estimated costs of hospital admissions for complications of chlamydial infection were more than double the costs of providing a routine chlamydia screening programme and prophylactic treatment. Screening for chlamydial infection before termination of pregnancy is essential. Prophylactic treatment for both chlamydial infection and anaerobic vaginosis should also be considered. Male partners of women infected with chlamydia are often symptom-free, but they must be traced to avoid reinfections.

Chlamydia trachomatis, infertility, and population growth in sub-Saharan Africa

In sub-Saharan Africa, Neisseria gonorrhoeae and Chlamydia trachomatis are common infections. These pathogens are also the major causes of post-salpingitis tubal infertility, and infertility is a frequent problem in this region. A mathematical model, recently devised to estimate the effect of gonococcal infection on population growth, was used to estimate the potential effect of chlamydial infection on population growth. The model predictions for chlamydial infection were compared with those previously reported for gonococcal infection. The model predicts that both infections may be exerting severe effects on population growth at realistic prevalence rates of infection. The model also predicts that N. gonorrhoeae produces a steeper reduction in population growth than does C. trachomatis because its transmission dynamics result in a higher force of infection (incidence rate) at any given prevalence of infection. Large scale changes in the epidemiology of these infections can be expected to occur in sub-Saharan Africa because of improved sexually transmitted disease (STD) diagnosis and treatment services as a component of AIDS prevention. Changes in the epidemiology of gonococcal and chlamydial infection are predicted to result in accelerated population growth unless STD control programs are linked to effective contraception programs.

Sexually transmitted diseases in the age of AIDS

Sexually transmitted diseases (STD) are common illnesses in the world. There is at least one new sexually transmitted disease consultation for every 100 persons a year in industrialised countries. Today the World Health Organisation estimates that there are 250 million new cases of STD every year world-wide, and over 20 distinct pathogens are currently recognised. While the overall incidence of STD have remained high in industrialised countries, the rates of increase of many bacterial STD such as syphilis and gonorrhoea were beginning to stabilise; but currently there is again a trend for these bacterial STD to rise in urban populations.

Reversible contraception for the woman over 35 years of age

Methods of reversible contraception, oral contraceptives, intrauterine devices, and Norplant (systemic progestin-only contraceptive; Wyeth-Ayerst, Radnor, PA), can be used for women over 35 years of age. Oral contraceptive formulations are safe and effective for healthy women up to the age of menopause. Oral contraceptives in women who do not smoke cigarettes do not result in a significant increased risk for cardiovascular disease. The incidence of breast cancer is not increased in women who have used oral contraceptives. A slight increase was found in younger women who had been on oral contraceptives based on a reanalysis of the contraceptive and steroid hormone study of the Centers for Disease Control. A reduction in the incidence of ovarian epithelial neoplasia by 40% was found in three European case-control studies. Two intrauterine devices are currently available on the US market: Paragard (GynoPharma, Somerville, NJ) and Progestasert (Alza Corp., Palo Alto, CA). Both of these provide highly effective contraception. A World Health Organization prospective randomized study found that there was an increase in pelvic inflammatory disease rates in the first 20 days after intrauterine device insertion. The intrauterine device itself did not increase the pelvic inflammatory disease incidence rates. The Norplant system exerts its contraceptive action through ovulation inhibition and alteration of cervical mucus. The major consumer complaint is irregular or prolonged uterine bleeding, which can be controlled by oral estrogen.

A survey of infertility, surgical sterility and associated reproductive disability in Perth, Western Australia

Infertility, surgical sterility and associated reproductive disability were studied in a stratified cluster sample of 1,511 couples with women aged 16 to 44 years resident in metropolitan Perth in 1988. Sixteen couples were omitted from analysis because of missing data. The proportion of couples affected by current infertility was 3.5 per cent (53 of 1,495), and 67.9 per cent of these (36 of 53) had a reproductive disability, meaning that they were unable to achieve their desired level of reproductive function. Those affected by surgical sterility accounted for 37.1 per cent (555 of 1,495), and of these couples 2.0 per cent (11 of 555) had a reproductive disability. Empirically, the prevalence of both infertility and reproductive disability peaked at ages 30 to 34 years in the female partner. Of the factors studied, infertility was associated with surgery for a ruptured appendix, a history of pelvic inflammatory disease and number of sexual partners. In 10 of the 47 couples with reproductive disability, contraceptive sterilisation had been a cause of later regret. Most other cases were due to infertility. Almost one half of couples with reproductive disability had sought treatment. The affected couples had at least one child from the current union in 23 of the 47 cases of reproductive disability. The results support the need for development of a strategy to prevent infertility and other causes of reproductive disability.

The role of the laboratory in a Chlamydia control programme in a developing country

The laboratory components of a Chlamydia trachomatis disease control programme for a developing country are reviewed. Early diagnosis of chlamydial infections is the most cost effective means of preventing the long term sequelae of trachoma, pelvic inflammatory disease, ectopic pregnancy and infertility, which are now a major public health burden to the health care system in developing countries. Public health strategies are required to establish both a co-ordinated limited system of laboratory services, and to promote the diagnosis and treatment of disease syndromes in the absence of laboratory support. Laboratory tests for the specific diagnoses of chlamydial infections requiring different levels of expertise and equipment can be instituted within settings appropriate to the resources and technical expertise available. Emphasis is given to appropriate cost effective utilization of laboratory testing.

Intrauterine devices and pelvic inflammatory disease: an international perspective

The risk of pelvic inflammatory disease (PID) associated with use of an intrauterine device (IUD) has been an important concern that has dominated decisions on its use throughout the world, especially in the USA. Early research that suggested such an association led to both a dramatic decline in use of the method and its withdrawal from the US market by two manufacturers. However, factors other than use of an IUD are now thought to be major determinants of PID risk. To address these concerns, we have reviewed the World Health Organisation's IUD clinical trial data to explore the incidence and patterns of PID risk with use of an IUD. The overall rate of PID among 22,908 IUD insertions and during 51,399 woman-years of follow-up was 1.6 cases per 1000 woman-years of use. After adjustment for confounding factors, PID risk was more than six times higher during the 20 days after insertion than during later times (unadjusted rates, 9.7 vs 1.4 per 1000 woman-years, respectively); the risk was low and constant for up to eight years of follow-up. Rates varied according to geographical area (highest in Africa and lowest in China) and were inversely associated with age. PID rates were lower among women who had IUDs inserted more recently. Our findings indicate that PID among IUD users is most strongly related to the insertion process and to background risk of sexually transmissible disease. PID is an infrequent event beyond the first 20 days after insertion. Because of this increased risk with insertion, IUDs should be left in place up to their maximum lifespan and should not routinely be replaced earlier, provided there are no contraindications to continued use and the woman wishes to continue with the device.

Pelvic inflammatory disease: cumulative incidence in primary care

The cumulative incidence of pelvic inflammatory disease (PID) among 2749 women aged 14-50 making contraception-related visits to 186 randomly selected Calgary family physicians participating in a 1986-1987 cross-sectional survey of physician attitudes and contraceptive prescribing was estimated to be 6.5%. For 10 consecutive working days after the doctors were interviewed, they completed a one-page checklist on every woman making a visit in which contraception was discussed beyond taking a history, including visits where the topic was opened by either the doctor or the patient, or where symptoms were suspected to be related to the use of contraception. Contraception-related visits accounted for 34.7% of all visits to the physicians by women aged 14-50. No definition of PID was provided to the physicians. The history of PID could have been elicited from the patient given or documented by the physician, or diagnosed at the time of the visit. A history of PID was more common among smokers than nonsmokers (11.0% vs 4.3%), and parous than nonparous women (8.8% vs 4.4%). Among women of Caucasian race/ethnicity, 6.2% vs 9.1% of women of other ethnicities had a history of PID. A larger proportion of low income than high income women (8.0% vs 5.3%) had a history of PID. The proportions of women with a PID history did not vary with marital status or age. The estimated 6.5% cumulative incidence is probably an underestimation of the true rate.

The role of Chlamydia trachomatis and Neisseria gonorrhoeae in the aetiology of ectopic pregnancy in Gabon

OBJECTIVE

To study the association between ectopic pregnancy and Chlamydia trachomatis and Neisseria gonorrhoeae.

DESIGN

A prospective observational study with two comparison groups.

SETTING

A general hospital in Franceville, Gabon.

SUBJECTS

Forty-five women with ectopic pregnancies and two comparison groups each of 45 women, one at 5 to 12 and the other at 32 to 41 weeks gestation.

MAIN OUTCOME MEASURES

Serum levels of IgG and IgA antibodies to C. trachomatis (L1 and rMOMP) and N. gonorrhoeae (pili) in all the women. In the women with ectopic pregnancy peritoneal adhesions were scored and in 40 women samples of tube were cultured for organisms being studied.

RESULTS

IgG and IgA antibodies to C. trachomatis (L1) were detected in 84% of the ectopic group and 53 and 39% of the comparison groups (P less than 0.0001). IgG and IgA antibodies to N. gonorrhoeae occurred in 49, 28 and 18% and 49, 28 and 26% of the groups but the differences were not statistically significant. Adhesions were positively associated with the antibodies. C. trachomatis was cultured from the tubes of 71% of the women with ectopic pregnancy.

CONCLUSIONS

Infection with chlamydia, and probably with N. gonorrhoeae, is an important factor in the causation of ectopic pregnancy in Gabon.

Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUDS

A levonorgestrel-releasing IUD and the Copper T 380Ag IUD were in randomized comparison for seven years in five clinics. In two other clinics the randomized study was truncated at five years, but use of the Copper T continued. No pregnancies occurred to users of either device in years 6 and 7. Cumulative pregnancy rates were 1.1 per 100 at seven years for the steroid-releasing and 1.4 per 100 for the copper-releasing IUDs. Cumulative rates of PID did not differ between devices. Infection rates appeared to be lowest during the sixth and seventh years of the study. Termination attributable to amenorrhea was the principal contributor to differences in cumulative continuation rates between devices. At the five clinics that carried the comparative study to seven years, cumulative continuation rates were 24.9 per 100 for LNg20 IUD users and 29.4 per 100 for TCu 380Ag users. Women who used either method for periods of five to seven years experienced, on average, marked to mild increases in hemoglobin as compared with levels at admission. The Copper T380 family and the LNg20 IUDs represent the most effective reversible contraceptive methods yet studied in long-term randomized trials.

Induced abortion: microbiological screening and medical complications

Preoperative cervical screening of 1,193 women undergoing first-trimester induced abortions yielded Chlamydia trachomatis in 11.7%, Neisseria gonorrhoeae in 0.8%, Mycoplasma hominis in 22.1%, Ureaplasma urealyticum in 10.1%, herpes simplex virus in 0.9% and Group B streptococci (GBS) in 2.9%. C. trachomatis and N. gonorrhoeae were especially frequent among teenagers. A total of 2.2% (26 women) developed postoperative pelvic inflammatory disease (PID) and 0.9% (13 women) endometritis. PID developed significantly more often in untreated chlamydia-positive (22.7%), M. hominis-positive (8.1%) and GBS-positive (6.1%) women than in women without these microbes (0.5%) (p less than 0.05). Prompt treatment of the chlamydia infection before or in connection with the abortion procedure significantly decreased the likelihood of developing chlamydial PID from 22.7% to 2.1% (p less than 0.001). The study confirms the importance of preoperative screening for chlamydia and suggests screening for M. hominis and GBS as well. The results of screening should be available before the abortion, allowing patients to be treated pre- or peroperatively.

Gonococcal peritonitis after tubal ligation. A case report

Gonococcal peritonitis occurred after a tubal ligation. Falk's postulated benefit of cornual resection as a preventive measure for recurrent infection does not extend to isthmic interruption. Pelvic inflammatory disease should be considered when a sterilized woman presents with an acute abdomen.

Risk factors for ectopic pregnancy: a case-control study in France, with special focus on infectious factors

A case-control study was conducted in 1988 in seven Paris area maternity hospitals to evaluate the role of several risk factors, particularly infectious factors, in ectopic pregnancy. A total of 279 cases and 279 controls were compared for sociodemographic characteristics, cigarette smoking, sexual, reproductive and surgical histories, and conditions of conception. Pelvic inflammatory disease confirmed by celioscopy (odds ratio (OR) = 5.5, 95% confidence interval (CI) 2.1-13.9) and Chlamydia trachomatis seropositivity (OR = 3.9, 95% CI 2.3-6.7) appeared to be important risk factors for ectopic pregnancy. Other risk factors found to be associated with an increased risk of ectopic pregnancy were dose-related cigarette smoking at the time of conception (ORs 1.3 to 2.5), appendectomy (OR = 1.6, 95% CI 1.1-2.5), prior tubal surgery (OR = 5.1, 95% CI 1.7-15.4), induced conception cycle (OR = 3.2, 95% CI 1.1-9.3), and prior ectopic pregnancy (OR = 13.3, 95% CI 4.5-39.2). However, some of the latter risk factors, i.e., prior tubal surgery, prior ectopic pregnancy, and perhaps appendectomy, may be considered to be the results of pelvic inflammatory disease and sexually transmitted diseases. Maternal age, parity, prior induced abortion, and prior spontaneous abortion were not associated with ectopic pregnancy. Use of intrauterine device, progestagen micropill, and also combined estroprogestative pill at the time of conception were associated with a better prevention of intrauterine pregnancy than of ectopic pregnancy. These findings confirm the importance of several previously reported risk factors of ectopic pregnancy: sexually transmitted diseases, cigarette smoking, and prior ectopic pregnancy. They also identified new risk factors, appendectomy and induced conception cycle, and revealed that the combined estroprogestative pill does not prevent ectopic pregnancy as effectively as it does intrauterine pregnancy.

Acute pelvic inflammatory disease after surgical sterilization

STUDY OBJECTIVE

Physicians are very cognizant of the possibility of pregnancy after surgical sterilization, but the potential for acute pelvic inflammatory disease (PID) is thought to be rare. This study was undertaken to determine if upper tract PID occurred more frequently than previously reported in patients remote from surgical sterilization.

DESIGN

Retrospective review of hospitalized patients with the primary discharge diagnosis of PID.

SETTING

Urban, university hospital.

PARTICIPANTS

Three hundred sixty-four hospitalized patients with the primary discharge diagnosis of PID over a six-year study period.

MEASUREMENTS AND MAIN RESULTS

Patients' age; gynecologic histories and diagnoses; and laboratory, clinical, and surgical findings were noted. Twenty-three cases of acute PID were identified in 21 patients previously sterilized (6%). Nine of the 23 cases had systemic toxicity warranting surgical evaluation; 18 of the 23 cases were admitted from the emergency department. Mean statistical characteristics of the study group were age, 27.3 +/- 0.8 (SE) years; time interval from sterilization, 49.8 +/- 7.4 months; WBC 15,000 +/- 1,200; and temperature, 38.0 +/- 0.2 C.

CONCLUSION

We conclude that acute PID may occur more frequently than previously reported in patients with prior surgical sterilization. An increased awareness of this entity is warranted.

[Chlamydia trachomatis infection in women and the use of oral contraceptives]

We determined the prevalence of genital Chlamydia trachomatis infection in women who visited a clinic for sexually transmitted diseases (STD) and the influence of the number of partners and the use of oral contraceptives (OC), with special attention to the recognition of pelvic inflammatory disease (PID) and to the results of therapy. Of 217 women, with a mean age of 26 years (range 14-56), who visited the STD clinic of the University Hospital of Groningen from July 1985 until November 1987, anamnestic data were collected as well as the results of swabs from cervix and urethra taken for culture and direct immunofluorescence test of C. trachomatis and for gonococcal culture. The influence of the number of partners (1 versus greater than 1) and OC on the prevalence of C. trachomatis infection was evaluated by logistic regression analysis. PID was excluded in coöperation with the department of gynaecology. C. trachomatis-infected women were treated by doxycycline orally (day 1 2 x 100 mg, day 2-7 1 x 100 mg) according to the dosage scheme advised by the Dutch Health Council in 1986. A control culture was taken 2-3 weeks after treatment. C. trachomatis was detected in 72/217 (33%) women by culture and (or) direct IF test and in 22/41 (54%) women with gonorrhoea. In connection with the number of partners in the year preceding the examination, the following prevalences were found: 18/74 (24%) (1 partner), 43/108 (40%) (2-5 partners) and 10/27 (greater than 5 partners).(ABSTRACT TRUNCATED AT 250 WORDS)

Clindamycin in the treatment of obstetric and gynecologic infections: a review

The spectrum of clindamycin's activity includes anaerobes and gram-positive aerobes other than enterococci. No inactivation or incompatibility of clindamycin phosphate has been shown in intravenous solutions usually used clinically. After oral administration, clindamycin is almost completely absorbed, with mean peak serum levels reached in 45 to 60 minutes. Clindamycin is widely distributed in many body fluids and tissues. Its normal half-life is two to three hours, and thus it can be given at six-hour intervals. Because of its excellent coverage against anaerobes, gram-positive cocci, and Chlamydia trachomatis, clindamycin is the preferred antimicrobial agent for serious infections of the female genital tract. Clindamycin plus tobramycin or an aminoglycoside is effective treatment for pelvic inflammatory disease, particularly when a tubo-ovarian abscess is present. In post-cesarean section endometritis, clindamycin plus gentamicin has been shown to be more effective than any other treatment. Clindamycin (alone or with an aminoglycoside) has been used successfully in posthysterectomy vaginal cuff infections and, with an aminoglycoside, in septic abortions. Clindamycin has been well tolerated in studies of animals and human subjects; its most significant side effects develop in the gastrointestinal system.

Reassessment of the metabolic effects of oral contraceptives

During the 30 years of experience with oral contraceptives, dramatic changes have occurred in their formulations and in prescribing practices. This article analyzes the latest information on the metabolic effects of oral contraceptives and makes recommendations for practice.

Pelvic inflammatory disease in the adolescent

We studied 171 women, 106 young adults, and 65 adolescents, with a clinical diagnosis of pelvic inflammatory disease (PID) to determine whether differences existed in the presentation in these two groups. The study population was an age-stratified, random sample obtained from 1162 women with this condition. Demographic characteristics, sexual history, physical findings, severity of illness, and laboratory findings were compared between the two groups. The most significant findings were that the adolescents sought health care later in the course of the illness (7.8 vs. 5.6 days; p less than 0.02) and were more commonly infected with the gonococcus (42% vs. 28%; p less than 0.05). No statistically significant differences were found in the other parameters evaluated. Implications of these findings regarding the health care for sexually transmitted diseases (STDs) and the education of adolescents are discussed.

Prevalence of bacterial vaginosis and its association with genital infections, inflammation, and contraceptive methods in women attending sexually transmitted disease and primary health clinics

In an epidemiological survey of 2128 women attending a sexually transmitted diseases clinic for the first time and 200 attending two primary health clinics, 26% and 27% respectively were found to have bacterial vaginosis. The prevalence increased significantly with age, being diagnosed in 22.8% (326/1431) of women aged 14-24 years, and in 33.3% (232/697) of those aged greater than or equal to 25 years. Bacterial vaginosis was associated with gonorrhoea and with chlamydial infection, but was negatively associated with genital papillomavirus infection and yeast infection. Women using barrier contraceptives had a significantly lower prevalence of bacterial vaginosis than those using an intrauterine device or no contraceptive. Women less than or equal to 24 years old using oral contraceptives had a significantly lower prevalence of bacterial vaginosis than those not using contraceptives. Patients without gonorrhoea or chlamydial infection but with vaginal or urethral inflammatory signs had a significantly higher prevalence of bacterial vaginosis than those without inflammatory signs. These findings may have implications regarding complications associated with lower genital tract infections and may strengthen the hypothesis that bacterial vaginosis is a risk factor for pelvic inflammatory disease.

First coitus before menarche and risk of sexually transmitted disease

The prevalence of sexually transmitted disease (STD), pelvic inflammatory disease (PID), and cervical cancer, and the relation between these conditions were studied in 2111 Ethiopian women. Early sexual activity was associated with an increase in prevalence rates of STD and PID; possible aetiological factors include physical and immunological immaturity of the female genital tract and the number of sexual partners.

Epidemiology of sexually transmitted diseases: the global picture

Sexually transmitted diseases (STD) are now the commonest group of notifiable infectious diseases in most countries, particularly in the age group of 15 to 50 years and in infants. Their control is important considering the high incidence of acute infections, complications and sequelae, their socioeconomic impact, and their role in increasing transmission of the human immunodeficiency virus (HIV). The worldwide incidence of major bacterial and viral STD is estimated at over 125 million cases yearly. STD are hyperendemic in many developing countries. In industrialized countries, the bacterial STD (syphilis, gonorrhoea, chancroid) declined from the peak during the Second World War till up to the late fifties, then increased during the sixties and early seventies, and they have been decreasing again from the late seventies till the present. In the industrialized world, diseases due to Chlamydia trachomatis, genital herpes virus, human papillomaviruses and human immunodeficiency virus are now more important than the classical bacterial ones; both groups remain major health problems in most developing countries. Infection rates are similar in both women and men, but women and infants bear the major burden of complications and serious sequelae. Infertility and ectopic pregnancies are often a consequence of pelvic inflammatory disease, and are preventable. Sexually transmitted diseases in pregnant women can result in prematurity, stillbirth and neonatal infections. In many areas 1-5% of newborns are at risk of gonococcal ophthalmia neonatorum, a blinding disease; congenital syphilis causes up to 25% of perinatal mortality. Genital and anal cancers (especially cervical cancer) are associated with viral sexually transmitted diseases (genital human papillomavirus and herpes virus infections). Urethral stricture and infertility are frequent sequelae in men.

[Fecundity, fertility, and sterility: assessment and controversy]

The author reviews problems concerning infertility in developed countries. Topics covered include natural fertility, "demographic and social trends in family planning such as increasing maternal age at first childbirth, the increase of age-specific infertility rates through known ([adnexitis]), unknown (the environment) or debatable (induced abortion, certain contraceptive methods) causes, and the availability of highly developed techniques to assist conception. The actual prevalence of infertility is poorly documented and is either derived from demographic surveys or from hospital populations. To record the true prevalence of infertility, population-based surveys including infertility specialist confirmation of the etiology are needed. One survey of this type indicates a lifetime prevalence of 17% of couples." (SUMMARY IN ENG)

Inhibition of Chlamydia trachomatis growth in endometrial cells by copper: possible relevance for the use of the copper IUD

There is agreement that the relative risk of developing pelvic inflammatory disease (PID) increases among women who use the intrauterine contraceptive device (IUD). The role of Chlamydia in causing PID among IUD users is not clear. The present study demonstrates that Chlamydia trachomatis growth can be inhibited in cultured human endometrial cells by copper ions at concentrations known to be released by the copper IUDs. More than 98% inhibition was produced with 10(-5) and 10(-6) M of copper. Both C. trachomatis serovar E and a lymphogranuloma venereum Chlamydia serovar L2 (LGV) were inhibited by the copper ions. Although the mechanism of the inhibition is not known, the continuous presence of the copper ions during and after adherence appeared to be necessary for maximal effect. If such inhibition occurs in vivo, it is possible that copper ions released from the copper-containing IUD may partially protect against chlamydial infection.

Pelvic inflammatory disease and the intrauterine contraceptive device

The relationship between the use of intrauterine contraceptive device (IUD) and pelvic inflammatory disease (PID) was examined in 1054 patients who were seen at the Family Planning Clinic of Jos University Teaching Hospital and were followed up. The overall risk of PID developing in women wearing the IUD was minimal: 62 out of 1054 (5.9%). The rates, however, varied for the 6-month periods studied. The incidence of PID decreased as the period of usage increased. The greater number of patients developed PID less than 3 months from the date of IUD insertion. When PID occurred it was usually of mild or moderate intensity and the response to antibiotic therapy was very encouraging. There was no relationship between the parity of the patients and the development of PID. Even though there is a definite link between the use of IUD and the development of PID it does not obliterate the benefits which the use of IUD provide for the majority of its patrons; and so the use of IUD should continue.

Removal of an intrauterine device and the treatment of acute pelvic inflammatory disease

The effect of removing intrauterine devices on the resolution of acute pelvic inflammatory disease was retrospectively studied in 186 hospital inpatients. In 105 patients the intrauterine device was left in place and in 81 it was removed on admission. The demographic and clinical findings in the two groups were similar. No differences were found between the two groups in their short-term response to treatment, except that when an intrauterine device was removed the time in hospital was more often prolonged.

Preventive lymecycline therapy in women with a history of pelvic inflammatory disease undergoing first-trimester abortion: a clinical, controlled trial

In a clinical, controlled trial 55 women with a history of pelvic inflammatory disease (PID) undergoing first-trimester abortion were randomized to either lymecycline therapy or placebo. Twenty-four women received lymecycline capsules 300 mg b.i.d. for 14 days starting on the morning of the abortion and 31 received similar placebo medication. In the lymecycline group 2 women (8.3%) and in the placebo group 7 (22.6%) contracted postabortal PID, a non-significant difference (p greater than 0.2). The variables age, gestational age, number of spontaneous abortions, births and episodes of PID, and Hegar size were not associated with the rate of postabortal PID. Women without previous induced abortions had a significantly increased rate of postabortal infection (p = 0.02), but the treatment did not influence this rate. Three women had a positive culture for Chlamydia trachomatis at the time of abortion and two of these had postabortal PID. None of 7 women with postabortal PID had significant increases in IgA, IgG or IgM chlamydia antibody titers, but two women with uncomplicated abortions had serological evidence of infection. The number of hospital days and amounts of antibiotics prescribed to women with postabortal PID were not significantly different between the two treatment groups (p greater than 0.05). Women with a history of PID had an elevated risk of postabortal PID warranting the use of some sort of prophylaxis, and screening for C. trachomatis in an abortion population is recommended.

The use of intrauterine contraceptive devices, pelvic inflammatory disease, and Chlamydia trachomatis infection

With the same epidemiologic approach taken in a recent study that suggested that oral contraceptive use may not protect against chlamydial pelvic inflammatory disease, the risks of chlamydial pelvic inflammatory disease were evaluated for intrauterine contraceptive device users. Compared with women using no method of contraception, intrauterine contraceptive device users were not found to be at any higher risk of cervical chlamydial infection. Whether this places intrauterine contraceptive device users at no increased risk of chlamydial pelvic inflammatory disease cannot be ascertained from the available data. Further research is needed before any conclusions can be made regarding the risks of chlamydial pelvic inflammatory disease to users of intrauterine contraceptive devices, oral contraceptives, and other contraceptive methods.

The prevention of sexually transmitted diseases which affect fertility: methodological problems and initial results

Sexually transmitted diseases and their consequences for fertility are currently a major preoccupation in public health. A joint research project is being carried out in France to develop an STD prevention program and then to implement it experimentally to evaluate its efficiency. It includes 2 phases: a feasibility phase, currently concluded, and an active phase, a community randomized trial. The aim of the feasibility phase was to test the research methods and tools and to act as a basis for the design of the prevention program. It measured the incidence of discharge (men and women) at a one-year interval and patient characteristics. Participating physicians were GPs in a French administrative department near Paris. Between the two measurements, information and sensitization actions were carried out in the same department among health professionals and the general public. The results show that the incidence of discharge (chosen here as indicators of STDs) in daily general medical practice is low, of the order of 6 cases per 1000 consultations. The community randomized trial will now be conducted in 6 French administrative departments, randomly divided into 3 treated departments, benefiting from a prevention campaign, and 3 controls, where no actions will be undertaken, and its results will be used in a national STD prevention campaign.

Prevention of sexually transmitted diseases in women

The frequency and severity of sexually transmitted diseases (STDs) and their sequelae, including sterility, numerous perinatal infections, genital tract neoplasia and possibly death (from ectopic pregnancy, ruptured tuboovarian abscess, human immunodeficiency virus-1 and hepatitis B virus infection), should be acknowledged by all sexually active individuals. Aspects of sexuality that place individuals at risk of STDs must be reexamined. Health care providers must effectively inform patients and the public of these often-ill-appreciated risks in a straightforward fashion, free of judgmental and punitive attitudes. New, more-effective means of prevention, diagnosis and treatment are being sought using research techniques in microbiology, immunology and behavioral science. In the meantime, medical screening, treatment and contact tracing should be carried out for patients and their sexual partners. Sexually active individuals must be empowered with knowledge and emboldened to protect themselves and their established or potential families from these common infections. Existing means of screening and treating must be utilized fully.

Intrauterine steroid contraceptives

Progestagen releasing IUDs were specially developed to diminish the problems of bleeding and pain with inert and copper containing IUDs. The intrauterine release of the progestagen causes endometrial atrophy, resulting in impairment of nidation, and interferes with transport of the ovum and the spermatozoa. Two available types, Progestasert, Biograviplan (Alza Corporation, California; Grünenthal) and Levonorgestrel Nova-T (Leiras Pharmaceuticals, Finland), have been sufficiently tested in multinational trials. Compared with Progestasert, LNG Nova-T showed lower pregnancy rates (Pearl Index 0.30), less risk for ectopic pregnancy and a longer effective lifetime (7 years). With both IUDs the amount and duration of menstrual blood loss is decreased. Amenorrhea is a frequent occurring side effect of LNG Nova-T, caused by endometrial atrophy. Intermenstrual blood loss and spotting incidences are not uniformly reduced and are still a frequent reason for removal. Preinsertion counselling may improve the acceptance of these non-health-threatening side effects. With both IUDs a decrease of menstrual cramps during periods is percepted and a low incidence of PID is found. Basically, the progestagen releasing IUD can be recommended to all women who wish an IUD for contraception and to women with contraindications for oral contraceptives, especially to those with menorrhagia, anaemia or risk for anaemia.

CO2 laser laparoscopy in infertile women with endometriosis and women with adnexal adhesions

One hundred twenty-four infertile women either with endometriosis (n = 70) or with adnexal adhesions (n = 54) were treated with the carbon dioxide laser used laparoscopically and were followed for 18 months. Removal of endometriotic implants, vaporization of endometrioma capsules, and lysis of adnexal adhesions was accomplished. Postoperative pregnancy rates were as follows: 57% for patients with endometriosis (mild, 62%; moderate, 52%; severe, 42%) and 57% for patients with adnexal adhesions. No serious complications requiring laparotomy were encountered. When performed, second-look laparoscopy confirmed efficient removal of endometriosis.