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Infections

A mild infection should be treated with the device left in situ

FACTS:

  • PID occurs in about 1 in 200 placements, usually within 21 days of placement and related to preexisting or newly acquired STI.
  • Risk factors for PID include positive chlamydial infection, bacterial vaginosis, cervicitis, and contamination of the endometrial cavity at placement.
  • While BV is a risk factor, routine screening for BV is not recommended.
  • If an IUC is placed in the setting of an asymptomatic positive swab for chlamydia or gonorrhea, the risk of PID is still quite low, at 0-5%.
  • Risk of PID does not increase with prolonged IUC use.
  • Elevated risk for STI acquisition is not a contraindication to IUC placement.

PID with an IUC in situ should be managed with any evidence – based PID regimen. If actinomyces effects were seen on cervical screening, therapy should include coverage for this bacteria. If infection is severe, and it is determined that the IUC is to be removed, delay removal for 24-48 hours until antibiotic therapy is established.
Click here to access the Canadian STI guidelines

Black D. and Waddington A. et al. Build Your Expertise: IUC slide deck: 28-29.
Costescu D. and Guilbert E. et al. Preceptorship Program on IUC insertion - Module 4
CDC- U.S. Medical Eligibility Criteria for Contraception Use, 2016

PID – Risk Factors

Risk factors for PID are multifactorial and need to be balanced against the risk of unintended pregnancy. Risk factors include:

  • History of STI or PID
  • Low socioeconomic status
  • Multiple partners
  • Inconsistent or non-use of condoms
  • Smoking
  • Young age

Studies comparing the risk of PID among women with chlamydia show that the risk of PID is NOT increased in IUC users compared to non-users.

Initiation of ANY highly effective method of contraception will increase the risk of STI if a woman who was previously using condoms stops using them. Any woman starting contraception should be counseled about reducing the risk of STI with barrier methods.

Reducing the risk of PID

  • Screening
    • Universal screening does not reduce the risk of PID. A selective approach is the most cost-effective and associated with similar rates of PID.
    • Women at elevated risk of STI (non-monogamy, history of STI, 25 or younger) should be screened at the time of placement.
    • An IUC should not be placed if there is mucopurulent discharge.
  • If the woman has a known positive result for chlamydia or gonorrhea, placement should be delayed until treatment is initiated. It may not be necessary to wait for a negative test of cure as this will further delay placement.
  • A ‘no touch’ placement technique should be used.

Awareness is vital!

  • Inform women of the increased risk of PID in the first 3 weeks following placement, usually related to existing infection.
  • Review signs and symptoms of PID in advance, and where to obtain care if she is concerned.
    • Continuous lower abdominal pain
    • Pelvic pain with fever
    • New onset discharge
  • If STI or PID develops with IUC in place
    • Treat using appropriate antibiotics for PID
    • There is usually no need for removal of IUC if the woman wishes to continue its use
    • No difference in clinical course if the IUC was removed or left in place
    • In the setting of hospitalization or severe PID, consider for removal after antibiotic therapy is established