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With the addition of the Mirena intrauterine system (IUS) [Berlex Laboratories, Montville, NJ] on the U.S. market, more women are taking a fresh look at the contraceptive method. What should you know about the intrauterine device (IUD) and the risk of pelvic inflammatory disease (PID) as you discuss the array of available birth control options?
Pelvic inflammatory disease is a broad term for any infection that ascends from the cervix into the uterus, fallopian tubes, and ovaries.1 Among American women of reproductive age, one in seven reports having received treatment for PID.2 Possible complications from the disease include ectopic pregnancy, pelvic abscess, and involuntary infertility.2
Epidemiologic research in the 1970s and 1980s tended to overestimate the risk of pelvic infection from IUD use.1 More recent research indicates that while IUD users are more likely
to develop PID than nonusers, it is still an uncommon complication.1 The greatest risk of PID occurs during the first few weeks following insertion; strict asepsis at insertion and leaving the IUD in place for its life span can reduce the chance of developing PID.2
However, the myth persists that IUDs increase the long-term risk of developing PID.2 The fact is that in properly selected patients, the IUD does not increase PID risk in the long term. The small risk immediately following insertion disappears at about 20 days.2
According to A Pocket Guide to Managing Contraception, the recommended patient profile for IUD candidacy includes parous women in stable mutually monogamous relationships (at low risk for sexually transmitted diseases) with no history of PID.3 However, nulliparous women at low risk for sexually transmitted diseases also might be candidates. Women with a history of PID might be candidates if they are in stable mutually monogamous relationships and have had a pregnancy since the PID episode.3
Apprehension about PID, especially in areas such as Africa where the sexually transmitted disease (STD) rate might be high, might cause patients, providers, and program managers to avoid IUDs. But what is the actual risk? This question is the basis of a recent review published by James Shelton, MD, senior medical scientist at the U.S. Agency for International Development in Washington, DC.4
On the basis of the data and possible difficulties presented, fully symptomatic PID attributable to IUD use is quite uncommon, even with high STD prevalence, Shelton concludes. Low STD prevalence favors the use of IUD even more, he states.
Shelton used existing data to calculate the risk of PID. His model of the risk of clinical pelvic inflammatory disease shows that the estimated risk is low (0.15%), even with a high STD prevalence. This estimated risk argues for making the IUDs more available, he states.
Sexually transmitted diseases are an important contraindication for IUD insertion. Since laboratory testing for STDs might not be possible in some developing countries, researchers are looking at the use of algorithms, a list of simple questions, to assess risk of infections.5
Scientists at Family Health International (FHI) in Research Triangle Park, NC, are planning to evaluate the use of risk assessment algorithms, developed to predict STD and subsequent IUD-related complications among IUD candidates, on some existing data sets of family planning populations, says Charles Morrison, PhD, senior epidemiologist in FHI’s clinical research division.
Morrison and other FHI researchers originally looked at the use of algorithms in examining the safety and complications related to IUD use among HIV-infected women in Kenya.6
By further researching the algorithms, the scientists hope to develop criteria that, rather than screening out women, will screen in the majority of women for whom there should be no barrier to IUD insertion, states Morrison.
1. Trieman K, Liskin L, Kols A, et al. IUDs — An Update. Population Reports. Series B, No. 6. Baltimore, MD: Johns Hop-kins School of Public Health, Public Information Program; December 1995.
2. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 17th revised ed. New York City: Ardent Media; 1998.
3. Nelson AL, Hatcher RA, Zieman M, et al. A Pocket Guide to Managing Contraception. Tiger, GA: Bridging the Gap Foundation; 2000.
4. Shelton JD. Risk of clinical pelvic inflammatory disease attributable to an intrauterine device. Lancet 2001; 357:443.
5. Best K. IUD not recommended for increased STD risk. Network 2000; 20:12-15.
6. Morrison CS, Sekadde-Kigondu C, Miller WC, et al. Use of sexually transmitted disease risk assessment algorithms for selection of intrauterine device candidates. Contraception 1999; 59:97-106. n
For more information on intrauterine devices and pelvic inflammatory disease, contact:
• James Shelton, MD, U.S. Agency for International Development. E-mail: JShelton@USAID.gov.
• Charles Morrison, PhD, Family Health International. E-mail: email@example.com.