Put myths to bed: Study shows IUD insertions don’t cause PID in women

Low risk shown following IUD insertion with same-day screening

Add new research to your clinic’s protocols: The risk of developing pelvic inflammatory disease (PID) following insertion of an intrauterine device (IUD) is very low, whether or not women have been screened beforehand for gonorrhea and chlamydia.

The findings come from a just-published retrospective cohort study.1 Scientists looked at 57,728 women, ages 14 to 49, who had a levonorgestrel intrauterine system or copper-T IUD inserted for contraceptive or non-contraceptive use between January 2005 and August 2009 at Kaiser Permanente Northern California in Oakland. To perform the study, researchers compared the date of the IUD insertion visit to the most recent gonorrhea and chlamydia screening date to categorize women into four screening groups: those who were screened on the same day as insertion; those screened from one day up to eight weeks before insertion; those tested from eight weeks up to one year before insertion; and those who received no screening within one year before insertion.

Previous research shows that the risk of upper genital tract infection is limited to the first 20 days after IUD insertion.2 However, researchers selected 90 days after insertion as the benchmark to be conservative in estimating the risk of PID. PID risks for the gonorrhea and chlamydia screening groups were compared by calculating unadjusted and adjusted risk differences and odds ratios with 95% confidence intervals (CIs), with adjustments for age and race, both factors known to be associated with PID.

The overall risk of PID was 0.54% (95% CI 0.48-0.60%). Nonscreening had an equivalent risk of PID as any screening (risk difference -0.0034, 95% CI -0.0045 to -0.0022), and the same-day screening was equivalent to prescreening (risk difference -0.0031, 95% CI -0.0049 to -0.0008). The equivalence persisted when adjusted for age and race and when stratified by age.1

The study results support IUD insertion protocols in which clinicians test women for Neisseria gonorrhea and Chlamydia trachomatis based on risk factors and perform the test on the day of insertion, the researchers conclude. “This study affirms that there is a low risk of pelvic inflammatory disease after IUD insertion, which has the potential to reduce barriers to IUD access, such as making women have a separate screening visit before the IUD insertion,” says lead author Carolyn Sufrin, MD, MA, assistant professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco in the San Francisco General Hospital Division and faculty member of the Bixby Center for Global Reproductive Health.

Why the wait?

The current study fills a large gap in the evidence base for the optimal timing and necessity of testing women who have no symptoms of gonorrhea or chlamydia prior to insertion of an intrauterine device, says Debbie Postlethwaite, RNP, MPH, assistant director of the Biostatistical Consulting Unit within the Division of Research at Kaiser Permanente in Oakland.

Data from the study provides evidence to support using the Centers for Disease Control and Prevention’s screening guidelines for testing for gonorrhea and chlamydia in women receiving IUDs,3 the same as with other contraception methods, says Postlethwaite, a study co-author. “If testing is indicated, based on the woman’s risk factors, our results suggest that it is safe to do so on the day of IUD insertion, with prompt treatment of positive results,” she says. “The most accurate time to clinically assess and screen for cervical infection is on the day of IUD insertion.”

Many providers require a recent negative gonorrhea and chlamydia test before inserting an IUD, which creates the need for multiple patient visits. This reluctance to perform insertions on the same visit dates to the 1970s, when the poor design of the Dalkon Shield IUD promoted upper genital tract bacterial infection and led to thousands of lawsuits, Postlethwaite observes.

Although the Dalkon Shield was removed from the market, it had a lasting negative impact on IUD use in the United States, says Postlethwaite. This lingering fear of PID leads many providers to require a recent negative gonorrhea and chlamydia test before inserting an IUD, thus creating the need for multiple patient visits. “This research proves that this is an unnecessary burden on the patient and, theoretically, a potential barrier to use of IUDs as a contraceptive option,” she states.

Today’s intrauterine devices are advanced in design beyond the Dalkon Shield. The Dalkon Shield had multi-filament threads that might have contributed to infections by acting as a wick to allow bacteria to ascend to the upper genital tract.4 Both a randomized controlled trial and cohort studies indicate that the monofilament thread used in current IUDs does not increase the risk of upper genital tract infection.5

According to the American College of Obstetricians and Gynecologists (ACOG), current data do not support routine screening for sexually transmitted infections (STIs) before IUD insertion for women at low risk of disease. For women at high risk of STIs (such as those age 25 or younger or those with multiple partners), it is reasonable to screen for STIs and place the IUD on the same day, ACOG guidance states. Treatment can be administered if the test results are then positive, or when the test results are available.6 An asymptomatic woman with a positive test result for chlamydia or gonorrhea at the time of IUD insertion may be treated and the IUD may be left in place, ACOG guidance states.

Should antibiotic prophylaxis be used prior to IUD insertion? Research points to “no.” In a meta-analysis of four randomized controlled trials of women with a low prevalence of STIs, antibiotic prophylaxis at the time of IUD insertion did not decrease the risk of PID, nor did it reduce the likelihood of removal within the first three months.7

Ground to gain

Intrauterine devices are among the safest, most effective methods of contraception and provide benefits in managing menorrhagia, chronic pelvic pain, and endometriosis, says Postlethwaite. Whereas the risk of pregnancy is 9% annually with pills, patches, and rings, IUDs offer highly effective contraception: less than one pregnancy per 100 women in one year.4 With their long-acting, yet reversible, properties, IUDs allow women almost complete control in planning their pregnancies, says Postlethwaite.

Nonetheless, the use of IUDs for contraception is very low, approximately 5%, in the United States.8 By comparison European countries average about 20%, says Postlethwaite.

“[Our] study corrects long-standing misperceptions that IUDs cause PID,” she notes. “The study affirms that there is a low risk of pelvic inflammatory disease after IUD insertion, which has the potential to reduce barriers to IUD access due to misperceptions.”

References

  1. Sufrin CB, Postlethwaite D, Armstrong MA, et al. Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease. Obstet Gynecol 2012; 120(6):1,314-1,321.
  2. Farley TM, Rosenberg MJ, Rowe PJ, et al. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1992; 339(8,796):785-788.
  3. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59(RR-12):1-110.
  4. Trussell J, Guthrie KA. Choosing a contraceptive: efficacy, safety and personal considerations. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
  5. Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet 2000; 356(9,234):1,013-1,019.
  6. Espey E, Ogburn T. Long-acting reversible contraceptives: intrauterine devices and the contraceptive implant. Obstet Gynecol 2011; 117(3):705-719.
  7. Grimes DA, Lopez LM, Schulz KF. Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database of Systematic Reviews 1999; 3:CD001327.
  8. Mosher WD, Jones J. Use of contraception in the United States: 1982-2008. Vital Health Stat 2010; (29):1-44.