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AFRICA HEALTH. 1993 Mar; 15(3):15-7.The real prevalence of pelvic inflammatory disease (PID) is unknown since many women are either asymptomatic or have atypical symptoms. It is often difficult to detect, manage, and prevent PID. Since PID has obstetric, gynecologic, and contraceptive-related causes, its prevalence is quite high. About 70% of PID hospital admissions in sub-Saharan Africa are a result of reproductive tract infections (RTIs) while this figure is 34% in Asia and 31% in developed countries. Only 10-20% of lower RTIs ascend into the upper genital tract and an even smaller percentage of women with PID develop chronic sequelae. Still, just 1 episode carries an increased risk of a tubal infertility, ectopic pregnancy, chronic pelvic pain, considerable pain during coitus, a new episode, and menstrual irregularities. Neisseria gonorrhoea and Chlamydia trachomatis are the most common causative organisms of PID. In Africa, the risk factors for PID are the same as they are for sexually transmitted diseases (STDs): multiple sex partners, young age at first intercourse, high frequency of coitus, and a high rate of acquiring new partners. The largest percentage of women with RTIs are monogamous women who are infected and constantly reinfected by their promiscuous husbands. The primary means to prevent PID are promotion of safer sexual behavior and condom usage. Secondary measures include accessible, acceptable, and effective STD services and education and counseling during case management. WHO suggests that STD treatment become part of the primary health care system. It has developed flow charts on syndromic diagnosis for urethral discharge in men and genital ulcer disease in women. Health workers should assume increased PID risk if the partner has had a history of urethral discharge and/or treatment for gonorrhea or nongonococcal urethritis. Partner notification is also needed for case management, but stigmatization in some countries poses a problem. WHO also recommends use of drugs which have a 95% STD cure rate.
PROGRESS IN HUMAN REPRODUCTION RESEARCH. 1992; (22):2-3.The WHO Special Programme of Research, Development and Research Training in Human Reproduction has conducted long term studies on 2 copper releasing IUDs (TCu220C and TCu380A) in almost 2800 women which show that they are effective for 9 years. The pregnancy rates for TCu220C at 7 and 9 years are 4.9 and 5.4/1000 woman years respectively. Thus the annual risk of pregnancy is about 1%. The pregnancy rates for TCu380A are even lower (1.7 and 2.1 respectively), an annual rate of less than 0.5%. As a result of these studies, the US Food and Drug Administration sanctioned TCu380A use for 8 years up from 6 years. More than 80 million women worldwide, especially in developing countries (e.g., about 74 million in China), use the IUD. Researchers have analyzed data on 22,908 insertions from 12 trials to see whether IUD use is related to pelvic inflammatory disease (PID) and whether long term use causes more severe PID. They learned that the overall PID rate is 1.6/1000 woman years. The first 20 days after insertion carry a 7 times higher risk of PID, but the risk falls considerably thereafter and stays low for at least 8 years. Further, duration of IUD use does not increase the severity of PID. WHO is supporting research at 28 centers which are evaluating a new IUD which has copper sleeves hanging from a nylon suture (frameless IUD). During insertion, the clinician embeds the suture superficially into the top of the uterus so the IUD and the copper sleeves are suspended. WHO is also supporting research at up to 6 centers on 2 modified frameless IUDs designed to be inserted after delivery. The research want to determine whether the high expulsion rate of IUDs inserted during the postpartum period can be reduced.
Lancet. 1992 Mar 28; 339(8796):783-4.It is difficult to determine if the IUD increases the risk of pelvic inflammatory disease (PID) because simple clinical features are not consistently predictive and can have low specificity and sensitivity. The C-reactive protein and the erythrocyte sedimentation rate tests help with PID diagnosis, but only a laparoscopy can determine tubal involvement. In 1970, WHO's Cooperative Statistical Programme found 2-year combined PID rates to range from 3.8 to 5.2/100 women with an IUD. Then WHO and various US organizations agreed IUD use did not necessarily cause PID. During the 1970s, however, a large rise in sexually transmitted diseases (STDs), especially chlamydia and gonorrhea, occurred and were associated with PID incidence. Many believed the growing rate of PID was attributable to the increasing use of IUDs. Many studies were biased because of overdiagnosis of PID. A 1990 review of 28 articles revealed that the overall PID rate was 1.49/100 woman years (lower than what many believed earlier). Some researchers used multicountry data on 22, 908 IUD insertions from WHO's data base for IUD studies to determine PID risk in IUD users. This risk was somewhat high during the 1st 20 days postinsertion which may be related to insertion, but PID rates in IUD users corresponded with those from the general population. PID rates did increase with age, however, and they did vary with geographical area. In addition, rates were 62% lower in women whose IUD was inserted after 1980. The PID rate was associated with background risk of STDs. These results and those of other studies suggest that health staff must adequately assess all patients before fitting the IUD and insert it only under strict aseptic conditions. IUDs that release copper and levonorgestrel pose a lower risk of PID than nonmedicated IUDs.
Lancet. 1985 May 4; 1(8436):1046.As part of a study on acute febrile pelvic inflammatory disease and IUDs, reported elsewhere, a significantly lower risk of PID was observed in women using injectable contraceptives. The World Health Organization coordinated the multinational case-control study in 1979-79. Diagnostic criteria were fever, suprapubic tenderness with guarding, cervical or adnexal tenderness or a pelvic mass. 319 cases and 639 matched controls were matched for age, parity, marital status and hospital status. Data were taken from questionnaires. 10 cases (3.1%) currently used injectable contraceptives, mainly Depo-Provera, compared to 38 controls (6.0%). Thus the risk of getting PID was half as great among injectable users, similar in magnitude to risks reported for women using oral contraceptives, barrier methods and sterilization in developing countries.
In: Intrauterine contraception: advances and future prospects, edited by Gerald I. Zatuchni, Alfredo Goldsmith, and John J. Sciarra. Philadelphia, Pennsylvania, Harper and Row, 1985. 354-64. (PARFR Series on Fertility Regulation)Little data is available from developing countries on the incidence of ectopic pregnancy and the associated risk factors: pelvic inflammatory disease (PID), sexually transmitted diseases (STDs), intrauterine devices (IUDs), and abortion. To address this problem, the World Health Organization conducted a multinational case-control study between 1978 and 1980 of factors associated with ectopic pregnancy in 12 centers, 8 in developing countries and 4 in developed countries. Results suggest that risk factors are similar in women from developing and developed countries. The only exceptions were increased risks of ectopic pregnancy associated with spontaneous abortion or smoking in developing but not developed country centers. This may reflect misreporting of illegal induced abortion or postabortion complications, and behavioral differences between smoking and nonsmoking women in developing countries. All methods of contraception prevent pregnancy and so provide protection against ectopic pregnancy. This protective effect is least with the IUD, however, and accidental conceptions during IUD use or after sterilization carry an increased risk of ectopic pregnancy. With the IUD, this probably reflects both differential protection against intrauterine and extrauterine pregnancy and an increased risk of IUD-related PID resulting in tubal damage. The risk of ectopic pregnancy is also increased in women with a previous history of PID or a prior pregnancy. However, cesarean section was found to reduce the risk of ectopic gestations in all comparison groups.
In: Zatuchni GI, Goldsmith A, Shelton JD, Sciarra JJ, ed. Long-acting contraceptive delivery systems. Philadelphia, Pa., Harper and Row, 1984. 621-7. (PARFR Series on Fertility Regulation)Progestasert (Alza Corporation, Palo Alto, California) achieves relatively high rates of contraceptive effectiveness through the release of a sex hormone--progesterone. Currently, it is recommended that Progestaserts be replaces every 12 months and most copper-bearing IUDs, every 3 years. To improve on Progestasert's 1-year replacement interval, Alza Corporation modified the Progestasert by increasing the amount of pregesterone contained in the IUD (from 38 to 52 mg) without changing the average daily release of 65mg. This long-acting progestasert, called the Intrauterine Progesterone Contraceptive System (IPCS), was designed to have a useful life of 3 years before replacement was required. The IPCS is identical in appearance to the Progestasert, and its contraceptive action in the same as that of the Progestasert. The effectiveness of either is through the effects of an intrauterine foreign body and through the effects of the progesterone on the encometrium. The IPCS system was designed to provide maximum contraceptive protection over a 3-year period and to reduce IUD-related bleeding, pain, and expulsion problems. Results from Alza monitored trials of the IPCS in the US and Mexico indicate that the cumulative life-table pregnancy rate increased from 3.6/100 women after 25 to 30 months of use to 10.6/100 women after 30 to 36 months of use. Laboratory evaluations of removed IPCS devices indicates that after 30 months of IPCS use the release rate of progesterone may not be adequate to prevent pregnancy effectively. The World Health Organization (WHO) evaluated the IPCS in 2 multiclinic studies. Postinsertion complications and complaints for the IPCS and T Cu-200 are shown. The include cervical perforation, ectopic pregnancy, pelvic inflammatory disease, dysmenorrhea, bleeding, spotting, and pelvic pain. The IPCS seemingly offers no particular advantages for use in developing countries.