9/18/05njm

Q. If a patient has an IUD and develops a Chlamydia infection, should
you remove the IUD?

A. The safest approach is to remove the IUD, but you can keep the IUD in
certain cases.

..in certain cases.....

IF you have an adherent patient who will fully cooperate with follow-up
plans, then the common recommendation is not to remove the IUD unless
PID is present.. There aren\'t data but clinical experience supports
this approach and follow-up is paramount. The risk for developing PID is
highest in the first 45 days after infection.

The patient will need a test of cure at 4 weeks and a re-screen in 3-4
months to rule out re-infection, which is common, especially in
adolescents. The test of cure is especially important in those treated
with erythromycin or amoxicillin and adolescents. The re-infection rate
in adolescents can be as high as 30% in some settings.

Regardless of the method above, the counseling, documentation and
informed consents should be meticulous. The patient should be confident
that her sexually transmitted infection (STI) risk is gone, e.g.,
partner no longer infected and has no other partner.

**[Background]{.underline}**

As there is not a great deal of data on this particular scenario, we
take a lot of our recommendations for the surrogate scenarios around IUD
insertion.

IUD insertion in women with postpartum endometritis, postabortion
infection, or active or recent (within three months) STDs (including
purulent cervicitis) increases the risk of upper genital tract
infection. There is no contraindication to use of the IUD in a woman
with a distant history of PID who has had a subsequent pregnancy and is
no longer at risk for STDs.

Signs of cervicitis should prompt screening for Gonorrhea and Chlamydia.
If such a sexually transmitted infection is identified and treated, IUD
insertion should be delayed until cure is confirmed. While no studies
have evaluated the outcome of IUD insertion in the presence of bacterial
vaginosis or Trichomonas, the device manufacturers recommend screening
and treatment if a suspicious vaginal discharge is identified.

**The main issues**

1.  Women with chlamydia or gonorrhea infections at the time of IUD
    insertion have been reported to have as much as an 11 percent risk
    of developing PID. Although this risk is relatively low, it is
    higher than the risk of developing PID in the absence of these
    pathogens (![](media/image1.png){width="8.333333333333333e-2in"
    height="9.236111111111112e-2in"}1 percent). For this reason, many
    clinicians always screen for gonorrhea and chlamydia prior to IUD
    insertion. However, the cost of universal bacteriologic screening is
    prohibitive in many settings, and no studies have evaluated the
    cost-effectiveness of routine screening in areas of low
    STD-prevalence.

2.  Awaiting results of STD screening tests could also delay device
    insertion in non-infected, low risk patients, thereby potentially
    leading to unintended pregnancy.

**Other issues**

**ANTIBIOTIC PROPHYLAXIS** --- There is a low risk of infection at the
time of IUD insertion with or without antibiotic prophylaxis. Antibiotic
use at the time of insertion (doxycycline 200 mg or azithromycin 500 mg
orally) has not been shown to be of benefit.

**Screening for STDs** --- There are insufficient data on the
cost-effectiveness of screening for sexually transmitted diseases (STDs)
before insertion. Screening for sexually transmitted diseases should be
considered in women with any risk factors for infection, and all
sexually active women under age 25 should undergo annual screening for
chlamydia. Women at high risk of PID should avoid use of the IUD.

A patient\'s greatest risk for developing pelvic inflammatory disease
(PID) is within the first 20 days after IUD insertion. This implies that
the pathogenesis of PID in new IUD users involves the introduction of
bacterial pathogens when the device is placed. Therefore, at a minimum,
it is important to look for signs of cervicitis or vaginitis, such as
mucopurulent cervical drainage or vaginal discharge, before inserting an
IUD.

Signs of cervicitis should prompt screening for Gonorrhea and Chlamydia.
If such a sexually transmitted infection is identified and treated, IUD
insertion should be delayed until cure is confirmed. While no studies
have evaluated the outcome of IUD insertion in the presence of bacterial
vaginosis or Trichomonas, the device manufacturers recommend screening
and treatment if a suspicious vaginal discharge is identified.

Whether routine screening for gonorrhea and chlamydia should be
performed in the absence of signs of infection is controversial. Women
with chlamydia or gonorrhea infections at the time of IUD insertion have
been reported to have as much as an 11 percent risk of developing PID.
Although this risk is relatively low, it is higher than the risk of
developing PID in the absence of these pathogens
(![](media/image1.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}1 percent). For this reason, many
clinicians always screen for gonorrhea and chlamydia prior to IUD
insertion. However, the cost of universal bacteriologic screening is
prohibitive in many settings, and no studies have evaluated the
cost-effectiveness of routine screening in areas of low STD-prevalence.
Awaiting results of STD screening tests could also delay device
insertion in noninfected, low risk patients, thereby potentially leading
to unintended pregnancy.

An alternative approach to universal screening is selective screening of
women at high risk of having an STD. The manufacturers of the TCu380A
and LNg 20 IUDs both take this approach and recommend gonorrhea and
chlamydia testing \"as indicated\" for the patient. As a public health
measure, the Centers for Disease Control and Prevention recommend
testing all sexually active women under the age of 26, as well as older
women who have risk factors for STD acquisition (such as a new or more
than one sexual partner) for STDs.

Applying these general guidelines to define the indications for pre-IUD
insertion screening may still miss a substantial number of infected
women in areas of high disease prevalence. Therefore, we feel the
decision for universal or selective screening pre-IUD insertion in
asymptomatic women should be based upon infection prevalence estimates
for the patient population in the provider\'s clinical setting. The
American College of Obstetricians and Gynecologists has stated that
there is insufficient information to determine the cost-effectiveness of
screening for STDs pre-IUD insertion.

**Women\'s Health Study**

To examine whether the risk of pelvic inflammatory disease associated
with intrauterine device (IUD) use varies with a woman\'s sexual
behavior, we analyzed data from the Women\'s Health Study, a
hospital-based, case-control study carried out in the United States from
1976-1978. The cases were 657 women hospitalized with pelvic
inflammatory disease; controls were 2566 women hospitalized with
nongynecologic conditions. After controlling for confounding factors, we
found no consistent differences in the risk of pelvic inflammatory
disease associated with IUD use among women in different categories of
gonorrhea history, frequency of intercourse, or number of recent sexual
partners. However, among women with only one sexual partner, married and
cohabiting women had little appreciable increased pelvic inflammatory
disease risk associated with IUD use compared with those using no
contraception, whereas previously and never-married women using IUDs had
relative risk estimates of 1.8 and 2.6, respectively. These results
suggest that women at low risk of acquiring sexually transmitted
infections have little increase in the risk of pelvic inflammatory
disease from use of an IUD.

Chlamydia Infections

Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2002. MMWR 2002; 51:RR-6

<http://www.cdc.gov/STD/treatment/4-2002TG.htm#Chlamydia>

**References:**

Grimes DA Intrauterine device and upper-genital-tract infection. Lancet
2000 Sep 16;356(9234):1013-9.

Hatcher, RA, Trussell, J, Stewart, F, et al. Contraceptive Technology,
17th ed, Ardent Media, Inc, New York 1998.

Grimes DA; Schulz KF Antibiotic prophylaxis for intrauterine
contraceptive device insertion. Cochrane Database Syst Rev
2001;(2):CD001327.

Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2002. MMWR 2002; 51:RR-6

<http://www.cdc.gov/STD/treatment/default.htm>

Lee NC; Rubin GL; Borucki R The intrauterine device and pelvic
inflammatory disease revisited: new results from the Women\'s Health
Study. Obstet Gynecol 1988 Jul;72(1):1-6.

Sinei SK; Schulz KF; Lamptey PR; Grimes DA; Mati JK; Rosenthal SM;
Rosenberg MJ; Riara G; Njage PN; Bhullar VB; et al. Preventing
IUCD-related pelvic infection: the efficacy of prophylactic doxycycline
at insertion. Br J Obstet Gynaecol 1990 May;97(5):412-9.

Sinei SK; Morrison CS; Sekadde-Kigondu C; Allen M; Kokonya D
Complications of use of intrauterine devices among HIV-1-infected women.
Lancet 1998 Apr 25;351(9111):1238-41.

**Resources**

**The intrauterine contraceptive device, UpToDate**

<http://www.uptodateonline.com/application/topic.asp?file=gen_gyne/15313&type=A&selectedTitle=1~22>

**Pathogenesis of and risk factors for pelvic inflammatory disease in
adults**

<http://www.uptodateonline.com/application/topic.asp?file=stds/2264>

**Insertion of an intrauterine contraceptive device**

<http://www.uptodateonline.com/application/topic.asp?file=gen_gyne/21041>