Nov 14, 2011

Recurrent PID Linked to Infertility, Chronic Pelvic Pain

Recurrent pelvic inflammatory disease (PID) is associated with an increased risk for infertility and chronic pelvic pain (CPP), according to a study published in the September issue of Sexually Transmitted Diseases.

Compared with women without recurrent PID, those who did have a recurrence were 80% more likely to experience fertility and 4 times as likely to have common pelvic pain.

Every year, PID is diagnosed in about 800,000 women in the United States. Potential complications of this disease include tubal infertility, ectopic pregnancy, and CPP. Studies conducted between 1960 and 1984 suggested that women with recurrent PID were at greater risk for reproductive complications than were women who did not experience recurrence.

Since those studies were conducted, the identification of the organisms that cause PID has changed. Previous studies identified Neisseria gonorrhoeae and Chlamydia trachomatis as the primary organisms associated with PID, but more recent research has shown that they now account for only about one third of cases.

Strategies for managing PID have also changed. In the past, patients with PID were admitted to the hospital, but currently, it is more common for patients to be treated on an outpatient basis.

To evaluate whether PID and subsequent sexually transmitted infections (STIs) cause reproductive complications, the researchers studied longitudinal secondary data from the PID Clinical Health and Evaluation (PEACH) study. A multicenter randomized clinical trial of PID treatment strategies, the PEACH study was conducted between 1996 and 1999. It included women aged 14 to 38 years who had mild to moderate PID.

Investigators considered 1515 women for inclusion; 831 eventually participated in the trial. Participants were randomly assigned to receive inpatient treatment (48 hours of intravenous cefoxitin [2 g every 6 hours] and oral doxycycline [100 mg twice daily] for 14 days) or outpatient treatment (1 intramuscular dose of cefoxitin [2 g] and oral probenecid [1 g], followed by a 14-day regimen of oral doxycycline [100 mg twice daily]).

Investigators instructed patients to rest and to abstain from sexual intercourse during the treatment period. Patients underwent a gynecologic examination and were tested for N gonorrhoeae (culture) and C trachomatis (polymerase chain reaction). Gram staining was used to test for bacterial vaginosis, and an endometrial biopsy was performed to assess for the presence of endometritis. Patients were reevaluated at 5 days and 30 days. Investigators contacted participants every 3 months for the next 84 months and assessed them for subsequent STI, PID, pelvic pain, and infertility.

Of the participants, 74.5% were black. At baseline, 43.8% were uninsured, 75.2% had had a previous pregnancy, and 37.4% had a previous diagnosis of PID. After 84 months, 21.3% had experienced PID recurrence, and 19.0% were considered infertile on the basis of a failure to conceive over a 12- month period during which they engaged in sexual intercourse without or with rare use of contraception.

The data were adjusted for age, race, parity, previous PID, N gonorrhoeae, and C trachomatis. Compared with women who did not have a recurrent episode of PID, women with recurrent PID had an adjusted odds ratio (AOR) for infertility of 1.8 (95% confidence interval [CI], 1.2 – 2.8); for CPP, the AOR was 4.2 (95% CI, 2.8 – 6.2).

For women who experienced subsequent STIs, the AOR for CPP was 2.3 compared with women who did not have subsequent STIs (95% CI, 1.2 – 3.2), but risk for infertility was not statistically significantly increased.

Among the adolescent subgroup (women aged 19 years or younger), the researchers found no statistically significant increase in risk for infertility (AOR, 1.9; 95% CI, 0.8 – 4.4), but these women had a much higher risk for CPP (AOR, 5.0; 95% CI, 2.3 – 10.6).

The investigators acknowledged that their study had certain limitations. For one thing, the results may not be generalizable to other populations. For example, more than 70% of the women in the study were using contraceptives, whereas other research suggests that less than 25% of women with PID are using contraception at the time of diagnosis. In addition, the outcome assessment depended on self-reported data.

In light of their results, the investigators recommended that healthcare providers link young women with PID to tailored risk-reduction services in an attempt to prevent the long-term consequences associated with the disorder.

The authors have disclosed no relevant financial relationships.

Sex Transm Dis. 2011;38:879-881. Abstract

— Jim King

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