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What are recommendations for PID treatment for a Mirena IUD user? #1208/9
Hello Dr. Hatcher, First of all, thank you for this website. It is an amazing resource of knowledge that is trustworthy. Thank you so much!

Here is my case history: I had my first Mirena IUD inserted (half-way through my cycle) this September. Three weeks later (just after my period) I discovered that it was expelling. Four days after that, I had the first Mirena removed and a second one immediately put in its place. Just over 48 hours later, had moderate-severe cramping, was doubled over in pain when walking and a fever of 100.5.

I was diagnosed with PID the next day (3 days after having the second Mirena inserted). The doctor who treated the PID was not my usual doctor. She opted to remove the IUD and put me on two types of antibiotics for 2 weeks. She said I have to wait 3 months before I can attempt to have a replacement put in.

My questions are: (A). What course of treatment would you recommend for a patient with an IUD and PID?
(B). Why is it that I have to wait 3 months before I can get another inserted?
(C). Are there higher risk factors (e.g. -expulsion, PID) for getting the 3rd Mirena inserted given my history?

Thank you,

Well, first of all, thank you for your kind words about this website.  It gives me pleasure to be able to reply in a helpful way to people’s questions.

 

Sorry you have had all these problems with this excellent contraceptive. 

 

 The question I might comment on is the removal of your Mirena IUD at the time PID was diagnosed.  Some would treat the PID with the IUD left in place, and many would do exactly what was done for you.  I also do not have much criticism for recommendation that you wait 3 months before reinserting your third IUD.

 

Several questions:

  1. How are you feeling now?  Any pain, bleeding or discharge? “I’m feeling fine.  However, I was diagnosed with bacterial vaginosis at the end of last week.  The symptoms were mild itching early in the week and thicker pinkish discharge towards the end of the week.  I am on a twice daily flagyl for a week.  My period just started yesterday, but before that there was still a bit of thicker discharge.”
  2. How old are you and how many children, if any, do you have? “I am 29 years old, single and have never been pregnant.”
  3. Have you ever had a pelvic infection in the past? “I had no prior history of pelvic infection.”
  4. For how long was it suggested that you wait to have vaginal sex?  Will you use condoms if you do have intercourse? “I think I was advised to wait 4-7 days (I don’t quite recall), and did wait the recommended time.  When I have intercourse, I use either condoms, my diaphragm or both.”
  5. Is there anything else you want me to know…anything? “Here is anything else that you may want to know: I tested clean for STIs both before the first insertion and when my second IUD was removed.  I had a depression-type reaction to several types of birth control pills (NuvaRing, Levora, and much more mildly so on Yasmin) and have been advised to not do hormonal birth control pills.  This was 3 years ago and I have relied on a diaphragm and condoms since then.”

“Thank you very much for your reply.  Sorry for the delay in my response, but I was waiting on the results of an appointment so I could update you on my current condition.  If you could please, tell me the reasoning behind a 3-month wait before inserting another IUD after a case of PID.”

 

“Given this additional information, are there higher risk factors (e.g. expulsion, PID) for getting the third Mirena IUD inserted, given my history?  I would really like to be able to have an IUD but I am uncertain what is the best course.”

 

“Many thanks!”

 

The reasoning is concern that you be over the initial infection.  Some clinicians would not suggest this long a delay.  After an expulsion, your risk for another expulsion is increased a bit.

Here is some further information for you:

 

Intrauterine Devices (IUDs) IN Contraceptive Technology 19th edition; Chapter by: David A. Grimes, MD

Expulsion

Between 2% to 10% of IUD users spontaneously expel their IUD within the first year. An IUD expulsion can occur without the woman detecting it. Nulliparity, an abnormal amount of menstrual flow, and severe dysmenorrhea are risk factors for Cu T 380A expulsion. A woman who has expelled one IUD has a 30% chance of subsequent expulsions.

 

The symptoms of an IUD expulsion include unusual vaginal discharge, cramping or pain, intermenstrual spotting, postcoital spotting, dyspareunia (for the man or the woman), absence or lengthening of the IUD string, and presence of the hard plastic of the IUD at the cervical os or in the vagina. If the menstrual period is delayed, check for IUD strings. A missed period may be the first indication of a “silent” expulsion. If the woman is not pregnant, another IUD can be replaced immediately.

Upper-genital-tract Infection

The risk of upper-genital-tract infection has been exaggerated due to flaws in early IUD research. Rigorous studies and reviews of the literature have established that the risk of infection and infertility among IUD users is very low.

 

Both epidemiological and bacteriological evidence indicates that the insertion process, and not the device or its string, poses the transient risk of infection. In the vagina, “strict asepsis” (widely recommended for the insertion process) is an oxymoron. No procedure that requires traversing the cervical canal can be devoid of all pathogenic organisms. Although sterile technique should be used, endocervical bacteria are routinely introduced to the endometrial cavity regardless of technique. 

 

Antibiotic prophylaxis should not be routinely used before insertion. Strong evidence supports the benefit of prophylactic antibiotics around the time of induced abortion; by analogy, the same might hold for endometrial contamination at IUD insertion. A large randomized controlled trial in Los Angeles County evaluated the potential benefit of prophylactic azithromycin given before IUD insertion.  Overall, no benefit was evident. The more important finding, however, was that salpingitis was rare with or without prophylaxis: only one women out of about a thousand in each group developed salpingitis in the early months of IUD use.

 

International experience with IUDs has been similarly favorable. In large World Health Organization-sponsored trials of IUDs, the risk of upper-genital-tract infection was limited to the first 20 days after insertion.  Afterwards, the risk returned to a low level and remained there for years. Both randomized controlled trial and cohort studies have revealed that the monofilament string does not increase the risk of upper-genital-tract infection.

 

Early assessments of the risk of tubal infertility among IUD users appear exaggerated as well.  Recent follow-up studies of IUD users discontinuing their contraception have found no significant differences in return to fertility, whether the IUD was removed because of a desire for pregnancy or because of problems with the IUD. This was true in both New Zealand and Norway. Indeed, the common problem among women who had had their IUDs removed was excess fertility, leading to induced abortions and unplanned births. Moreover, in a Mexican case-control study, prior copper IUD use was not significantly related to documented tubal pathology, whereas the presence of Chlamydia antibodies was. Again, this underscores the point that sexually transmitted diseases, not contraception, cause salpingitis.

 

Little is known about the potential effect of an IUD on acquiring a cervical or vaginal sexually transmitted infection. Fair evidence refutes an increased risk of chlamydial infection, but no evidence is available concerning gonorrhea.  Women who harbor sexually transmitted infections in their cervices have an increased risk of upper-genital tract infection, regardless of their IUD status. However, whether the IUD contributes in any way to that risk is unknown. No study to date has used the appropriate comparison group: women with an STI not having an IUD insertion. The comparison group has always been women with an IUD but without an STI, which addresses a different question.

 

Upper-genital-tract infection needs prompt treatment and follow-up. Accurate diagnosis is often difficult. Widely used diagnostic criteria for acute salpingitis have been found invalid, and atypical salpingitis may be more common. Hence, when in doubt, treat.

 

The Centers for Disease Control and Prevention has published recommendations for both inpatient and outpatient therapy of upper-genital-tract infection (Chapter 21 on Reproductive Tract Infections).  All involve two antibiotics in order to provide an adequate spectrum of coverage. Male partners of women thought to have salpingitis should be examined and treated presumptively according to guidelines. Some clinicians recommend IUD removal along with antibiotics. However, evidence for this recommendation is limited.  Indeed, one small randomized controlled trial showed no benefit of IUD removal as an adjunct to antibiotic therapy.

 

Her reply 1-13-2010: “Hello again Dr. Hatcher.”

 

“I wanted to update you on my case.  I had another Mirena successfully inserted today.  The procedure went very well and I hope this one will stay in place.”

 

“Thank you very much for your earlier guidance.  I really do appreciate the effort that gets put into the site.  It has helped on numerous occasions.”

 

 

RAH’s reply on 1-15: The rationale for waiting 3 months is to be sure all infection is cleared.  Some clinicians would insert an IUD sooner than 3 months once PID has been adequately treated. 

 

Remember that the IUD does not cause PID: it is the various organisms that can be transmitted at the time of intercourse that cause PID.

 

I would suggest that you use condoms for the weeks ahead and perhaps longer.

 

Hope that you do not expel your Mirena IUD this time.  Please keep me posted.


Key Words: 
Mirena IUD, inserted, cycle, period, cramping, diagnosed, PID, antibiotics, higher risk factors, expulsion, contraceptive, pain, discharge, infection, vaginal sex, condoms, bacterial vaginosis, symptoms, itching, flagyl, diaphragm, STIs, depression-like reaction, birth control pills, NuvaRing, Yasmin, hormonal contraceptives, Contraceptive Technology, Intrauterine Devices, Dr. David A. Grimes

 

Reference:

Grimes DA. Intrauterine devices (IUDs) IN Hatcher RA, Trussell J, Nelson AL. et al Contraceptive Technology 19th edition, pages 124-127: Ardent Medial Ind. 2008

  

Robert A. Hatcher MD, MPH
Emeritus Professor of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, GA
---2010-01-15


Managing Contraception for Your Pocket 2013-2014
  


Managing Contraception for Your Pocket 2013-2014
  

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