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Actinomyces in cervical smears of women using the intrauterine device in Singapore
Contraception 73 (2006) 352 – 355
Original research article
Actinomyces in cervical smears of women using the intrauterine device in Singapore Vanaja Kalaichelvan, Aye Aye Maw, Kuldip SinghT Department of Obstetrics and Gynaecology, National University Hospital, Singapore 119074, Singapore Received 28 June 2005; revised 29 July 2005; accepted 7 September 2005
Abstract Objectives: Reproductive tract actinomyces have been associated with the use of intrauterine contraceptive device (IUCD). Thus, there is a need to evaluate the prevalence of colonization with Actinomyces israelii in a cohort of Singaporean women using an IUCD. Second, the occurrence of actinomycosis in colonized women and the clinical need to remove the IUCD and/or possibly the need to treat asymptomatic carriers with antibiotics were evaluated. Methods: The study population consisted of 1108 IUCD users attending the Fertility Control Clinic, National University Hospital, Singapore. Results: In our study, the prevalence of actinomyces-positive cervical smears among IUCD users was 13.7%; the incidence of actinomycespositive smears was similar with Copper T (34.2%), Multiload (32.9%) and Nova T (32.9%) IUCDs. We found no association with the duration of use of IUCD and actinomyces infection. In our study, 150 out of 152 (98.7%) IUCD users with actinomyces-positive smears were asymptomatic, and only 2 out of 152 (1.3%) who had actinomyces-positive cervical smears developed pelvic inflammatory disease at 6 months. Conclusions: Our study suggests that removal of the IUCD in asymptomatic women with actinomyces-positive cervical smear is not necessary. Moreover, we suggest that asymptomatic carriers of actinomyces do not require preemptive antibiotic treatment. D 2006 Elsevier Inc. All rights reserved. Keywords: Actinomyces; Cervical smears; Intrauterine device use
1. Introduction Actinomyces are anaerobic Gram-positive non-sporeforming filamentous bacteria that are present in the normal flora of the mouth, the pharynx and probably the lower ileum and cecum [1,2]. Actinomyces in the mouth, cecum or ileum can invade local tissues in the pelvis. Actinomyces of the female genital tract is a rare but potentially morbid disease. Female reproductive tract actinomyces have been associated with the use of an intrauterine contraceptive device (IUCD). Actinomyces-causing pelvic inflammatory disease (PID) is uncommon [1,2]. In 1996, Sandra et al. [1] reported on two women having invasive pelvic actinomycosis in the presence of an IUCD. Actinomyces-like organism (ALO) had already been seen in the women’s cervical smears taken 3 and 7 years before development of their invasive T Corresponding author. Tel.: +65 67724261, fax: +65 67794753. E-mail address: [email protected] (K. Singh). 0010-7824/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2005.09.005
actinomyces, respectively. At the time of the positive smears, they did not receive any treatment, neither IUCD removal nor antibiotics. This finding illustrates that colonization by actinomyces can exist in women for a considerable period before invasion is manifest [1]. In the present study, we first evaluated the prevalence of colonization and clinical infection with Actinomyces israelii in a cohort of Singaporean women using an IUCD. Secondly, we evaluated the occurrence of actinomycosis in colonized women and the clinical need to remove the IUCD or treat asymptomatic carriers with antibiotics. 2. Methods The study population consisted of 1108 healthy IUCD users attending the Fertility Control Clinic of the National University Hospital, Singapore. The subjects ranged in age from 20 to 40 years. The duration of IUCD usage ranged from 1 to 6 years. The exclusion criteria included pregnancy, past history of PID, any severe systemic disease
V. Kalaichelvan et al. / Contraception 73 (2006) 352 – 355 Table 1 Actinomyces-positive smears in different IUCD groups
353
3. Results
Type of IUCD
Copper T
Multiload
Nova T
Actinomyces-positive, n (%)
52 (34.2)
50 (32.9)
50 (32.9)
or malignancy that may impair the immune system, allergy to the antibiotics used or the use of any medication known to affect the metabolism or pharmacokinetics of the antibiotics to be used. All participants gave informed and written consent before enrolment. The study was approved by the Institutional Review Board of the National University Hospital. Cervical smears were taken from the women when they attended the Fertility Control Clinic. The smears were immediately fixed in 95% alcohol. Bimanual pelvic examination was done to exclude the clinical evidence of PID. The cervical smears were stained with the Papanicolaou stain and were screened for evidence of inflammation and other cellular change. Examination of cervical smears showed ALO in 152 of the 1108 IUCD users. This was based on the observation of bcotton ballQ clusters. The clusters are composed of tangled clumps of filamentous organisms with acute angle branching. The filaments could sometimes have a radial distribution or have an irregular bwoolly bodyQ appearance. These smears were all doubly read by two cytologists, as is the standard in our cytological laboratory. Actinomyces-positive women were questioned for any evidence of symptoms and signs suggestive of PID such as abdominal pain, fever and/or vaginal discharge. Bimanual pelvic examination was performed to rule out the presence of PID. Fornices tenderness, pelvic induration and adnexal swelling were taken as symptoms suggestive of pelvic inflammation. All women with positive smears had pelvic ultrasound examination to exclude presence of PID. In order to compare the treatment modalities for actinomyces-positive asymptomatic women, the 152 women with actinomyces-positive cervical smears were randomly allocated into four groups: Group 1 (25%) had no treatment; Group 2 was given penicillin V 500 mg three times a day for 2 weeks; Group 3 was given doxycycline 100 mg twice a day for 2 weeks; Group 4 was treated with metronidazole 400 mg three times a day for 2 weeks. The number of women in each group was 38. The choice of antibiotics was based on a literature search of current regimens used for the treatment of actinomycosis. All 152 women had follow-up visits at 3 and 6 months. History was taken at each visit for symptoms suggestive of PID. All had bimanual pelvic examination to look for signs suggestive of PID. Each woman had repeat cervical smears at each follow-up visit for ALO. Statistical analyses were performed using SPSS 12.0. The differences in evaluating the symptoms between treatment modalities were assessed using v 2 or Fisher’s Exact Test. Statistical significance was set at pb .05.
3.1. Incidence Cervical smears from 1108 IUCD users attending our Fertility Control Clinic were examined for the presence of actinomyces organisms. Among the 1108 IUCD users, 152 women were positive for actinomyces organisms, giving a prevalence rate of 13.7% (95% confidence interval, 11.8–15.9%). 3.2. Types of IUCD used Of the 152 women with actinomyces-positive smears, 52 women were using the Copper T, 50 were using the Multiload and 50 were using the Nova T (Table 1). No particular type of IUCD was specifically associated with the presence of actinomyces infection. The type of IUCD used did not appear to be an important risk factor. 3.3. Evidence of PID All 152 women with actinomyces-positive smears were asymptomatic. None had symptoms and signs suggestive of PID at the time of original confirmation. An ultrasound examination of the pelvis was done following detection of a positive actinomyces smear. In all 152 women, there was no evidence of any PID on ultrasound examination. 3.4. Modality of treatment None of the 38 women in the control or bno-treatmentT group showed any symptoms or signs of PID on follow-up. At 3 months’ follow-up, the smear in 17 out of 38 (44.7%) women showed absence of actinomyces organisms. At 6 months, 24 out of 38 (63.2%) women showed no evidence of actinomyces organisms. None of the 38 women in this group had removal of the IUCD. In the group who received penicillin V treatment, 16 out of 38 (42.1%) women showed absence of actinomyces organisms at the 3 months’ follow-up; the number increased to 23 (60.5%) at the 6 months’ follow-up. One woman in this group presented with increased vaginal discharge and abdominal pain at 5 months following the finding of actinomyces-positive smear. Clinical and ultrasound examination confirmed the presence of PID. Her IUCD was removed and she was treated effectively with other antibiotics for PID. Of the 38 women on doxycycline treatment, 15 (39.5%) had smears negative for actinomyces organism at 3 months. Table 2 Actinomyces-negative cervical smears at 3 months’ follow-up Type of treatment
No. of actinomyces-negative smears at 3 months’ follow-up (%)
Values of p as compared to control group
No treatment (n = 38) Penicillin V (n = 38) Doxycycline (n = 38) Metronidazole (n = 38)
17 16 15 19
1.000 .815 .490
(44.7) (42.1) (39.5) (50.0)
354
V. Kalaichelvan et al. / Contraception 73 (2006) 352 – 355
Table 3 Actinomyces-negative cervical smears at 6 months’ follow-up Type of treatment
No. of actinomyces-negative smears at 6 months’ follow-up (%)
Values of p as compared to control group
No treatment (n = 38) Penicillin V (n = 38) Doxycycline (n = 38) Metranidazole (n = 38)
24 23 22 21
.830 .639 .484
(63.2) (60.5) (57.9) (55.3)
The number increased to 22 (57.9%) at 6 months’ followup. One woman in this group presented with symptoms and signs of PID at her 6 months’ follow-up. Ultrasound showed normal findings. Nevertheless, her IUCD was removed and she was treated effectively for PID. Another woman had her IUCD removed at 6 months for personal reasons. In the group treated with metronidazole, 19 out of 38 (50.0%) women had cervical smears negative for actinomyces organism at 3 months. At 6 months, 21 out of 38 (55.3%) smears were negative. None of the women in this group had symptoms and signs suggestive of PID. There were no removals of IUCDs in this group. When the three treatment groups were compared to the control/no treatment group, there was no significant difference noted in the reduction of actinomyces-positive smears at 3 months (Table 2) and 6 months (Table 3) followup, respectively. 3. Discussion The IUCD is an effective contraceptive method and has the unique advantage of being a one-time reversible method with minimum side effects and no user compliance. However, its usage has been associated with increased incidence of vaginal infection and PID. Genital actinomyces was thought to be rare but has recently been reported with increasing frequency in association with IUCD use [1–4]. The literature suggests that the incidence of actinomycespositive cervical smears range from 1.6% to 44% [1–6]. Part of this variability can be explained by different levels of stringency applied in the evaluation of cervical smears, and possibly misinterpretation. In our study, the prevalence of actinomyces-positive cervical smear among IUCD users was 13.7%. Differing rates of colonization with actinomyces have been reported with the use of different types of IUCDs. Copper-containing IUCDs have been reported to have lower rates of colonization with A. israelii compared with other IUCDs [1]. In the present analysis, we were not able to find any difference between the presence of actinomyces organism and the type of IUCD [2,5,6]. The incidence of actinomyces positive cervical smear was similar with Copper T, Multiload and Nova T IUCDs in our study. Curtis and Pine [5] found that the chance of colonization with actinomyces increases with the duration of the use of an IUCD. There appears to be a direct relationship between the duration of IUCD usage and the development of actinomyces
infection [5,6]. In our study, we found no significant association between the duration of use of IUCD with regard to the incidence of ALO in cervical smears (data not shown). It is reported in the literature that the majority of IUCD users having actinomyces-positive smears are asymptomatic. In our study, 150 out of 152 (98.7%) IUCD users with actinomyces-positive smears were asymptomatic. The low incidence of endometriosis and salpingitis detected supports the view that A. israelii spreading from a colonization during IUCD use to infect the endometrium and further spread to the fallopian tubes causing symptomatic pelvic infection is not common, and if it does occur, it may be related to conditions where there is a specific preceding tissue damage [1,2]. The management of women with actinomyces-positive smears in the absence of significant symptoms is unsettled. It ranges from leaving the device in situ with no treatment, treatment with antimicrobials without removal of the IUCD, to removal of the IUCD in both symptomatic and asymptomatic women followed by antimicrobial treatment. Gupta et al. [6] and Luff and Gupta [7] recommended simple removable of the IUCD in both asymptomatic and symptomatic women, with the use of antibiotics only in symptomatic women. Garland and Rawling [8] recommended removal of the IUCD in both asymptomatic and symptomatic women and treatment of all colonized women with penicillin V. The current view of the American College of Obstetricians and Gynecologists and the Royal Australia and New Zealand College of Obstetricians and Gynecologists is that the IUCD need not be removed in asymptomatic women with actinomyces-positive smears [9–11]. Furthermore, in the absence of confirmation of pelvic infection by cultures, there is no need to treat such asymptomatic women with positive actinomyces smears [7,8]. In the present study, we have shown that only 2 out of 152 (1.3%) women with actinomyces-positive cervical smear developed PID at 6 months’ follow-up with the majority (98.7%) remaining asymptomatic. The results of our large perspective study suggest that there is no necessity to treat with antibiotics asymptomatic IUCD users who have actinomyces-positive cervical smears at follow-up. 5. Conclusion This study suggests that removal of the IUCD in asymptomatic women with actinomyces-positive cervical smears is not necessary. Moreover, we suggest that asymptomatic women with actinomyces-positive cervical smears do not require treatment with antibiotics. References [1] Sandra M, Oosterhof H, Van Dissel JP. Letter to editor: actinomyces and the intrauterine device. Arch Intern Med 1998; 158:1270.
V. Kalaichelvan et al. / Contraception 73 (2006) 352 – 355 [2] Charnock Chamber TJ. Pelvic actinomycosis and intrauterine contraceptive devices. Lancet 1970;1239 – 40. [3] Florino AS. Review — IUCD associated actinomycotic abscess and actinomyces detection on cervical smear. Obstet Gynaecol 1996;87: 142 – 9. [4] Cleghorn AG, Wilkinson RG. The IUCD associated incidence of Actinomyces israelii in the female genital tract. Aust N Z J Obstet Gynaecol 1989;29(4):445 – 9. [5] Curtis EM, Pine L. Actinomyces in the vagina of women with and without intrauterine contraceptive devices. Am J Obstet Gynecol 1981;140:880 – 4. [6] Gupta PK, Hollender DH, Frost JK. Actinomyces in cervical–vaginal smears: an association with IUD usage. Acta Cytologica 1976;20: 295 – 7.
355
[7] Luff RD, Gupta PK. Actinomyces-like organisms in wearers of intrauterine contraceptive devices. Am J Obstet Gynecol 1977;129: 476 – 7. [8] Garland SM, Rawling D. Pelvic actinomycosis in association with intrauterine device. Aust N Z J Obstet Gynaecol 1993;33:96 – 8. [9] Royal Australian and New Zealand College of Obstetricians and Gynaecologists Intrauterine Contraceptive Devices and Infection. C-Gyn 3, 2003. [10] IPPF. Medical advisory panel statement on intrauterine devices. IPPF Med Bull 1995;29:6. [11] Hager WD, Majmudar B. Pelvic actinomycosis in women using intrauterine contraceptive devices. Am J Obstet Gynecol 1979;133: 60 – 3.
Original research article
Actinomyces in cervical smears of women using the intrauterine device in Singapore Vanaja Kalaichelvan, Aye Aye Maw, Kuldip SinghT Department of Obstetrics and Gynaecology, National University Hospital, Singapore 119074, Singapore Received 28 June 2005; revised 29 July 2005; accepted 7 September 2005
Abstract Objectives: Reproductive tract actinomyces have been associated with the use of intrauterine contraceptive device (IUCD). Thus, there is a need to evaluate the prevalence of colonization with Actinomyces israelii in a cohort of Singaporean women using an IUCD. Second, the occurrence of actinomycosis in colonized women and the clinical need to remove the IUCD and/or possibly the need to treat asymptomatic carriers with antibiotics were evaluated. Methods: The study population consisted of 1108 IUCD users attending the Fertility Control Clinic, National University Hospital, Singapore. Results: In our study, the prevalence of actinomyces-positive cervical smears among IUCD users was 13.7%; the incidence of actinomycespositive smears was similar with Copper T (34.2%), Multiload (32.9%) and Nova T (32.9%) IUCDs. We found no association with the duration of use of IUCD and actinomyces infection. In our study, 150 out of 152 (98.7%) IUCD users with actinomyces-positive smears were asymptomatic, and only 2 out of 152 (1.3%) who had actinomyces-positive cervical smears developed pelvic inflammatory disease at 6 months. Conclusions: Our study suggests that removal of the IUCD in asymptomatic women with actinomyces-positive cervical smear is not necessary. Moreover, we suggest that asymptomatic carriers of actinomyces do not require preemptive antibiotic treatment. D 2006 Elsevier Inc. All rights reserved. Keywords: Actinomyces; Cervical smears; Intrauterine device use
1. Introduction Actinomyces are anaerobic Gram-positive non-sporeforming filamentous bacteria that are present in the normal flora of the mouth, the pharynx and probably the lower ileum and cecum [1,2]. Actinomyces in the mouth, cecum or ileum can invade local tissues in the pelvis. Actinomyces of the female genital tract is a rare but potentially morbid disease. Female reproductive tract actinomyces have been associated with the use of an intrauterine contraceptive device (IUCD). Actinomyces-causing pelvic inflammatory disease (PID) is uncommon [1,2]. In 1996, Sandra et al. [1] reported on two women having invasive pelvic actinomycosis in the presence of an IUCD. Actinomyces-like organism (ALO) had already been seen in the women’s cervical smears taken 3 and 7 years before development of their invasive T Corresponding author. Tel.: +65 67724261, fax: +65 67794753. E-mail address: [email protected] (K. Singh). 0010-7824/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2005.09.005
actinomyces, respectively. At the time of the positive smears, they did not receive any treatment, neither IUCD removal nor antibiotics. This finding illustrates that colonization by actinomyces can exist in women for a considerable period before invasion is manifest [1]. In the present study, we first evaluated the prevalence of colonization and clinical infection with Actinomyces israelii in a cohort of Singaporean women using an IUCD. Secondly, we evaluated the occurrence of actinomycosis in colonized women and the clinical need to remove the IUCD or treat asymptomatic carriers with antibiotics. 2. Methods The study population consisted of 1108 healthy IUCD users attending the Fertility Control Clinic of the National University Hospital, Singapore. The subjects ranged in age from 20 to 40 years. The duration of IUCD usage ranged from 1 to 6 years. The exclusion criteria included pregnancy, past history of PID, any severe systemic disease
V. Kalaichelvan et al. / Contraception 73 (2006) 352 – 355 Table 1 Actinomyces-positive smears in different IUCD groups
353
3. Results
Type of IUCD
Copper T
Multiload
Nova T
Actinomyces-positive, n (%)
52 (34.2)
50 (32.9)
50 (32.9)
or malignancy that may impair the immune system, allergy to the antibiotics used or the use of any medication known to affect the metabolism or pharmacokinetics of the antibiotics to be used. All participants gave informed and written consent before enrolment. The study was approved by the Institutional Review Board of the National University Hospital. Cervical smears were taken from the women when they attended the Fertility Control Clinic. The smears were immediately fixed in 95% alcohol. Bimanual pelvic examination was done to exclude the clinical evidence of PID. The cervical smears were stained with the Papanicolaou stain and were screened for evidence of inflammation and other cellular change. Examination of cervical smears showed ALO in 152 of the 1108 IUCD users. This was based on the observation of bcotton ballQ clusters. The clusters are composed of tangled clumps of filamentous organisms with acute angle branching. The filaments could sometimes have a radial distribution or have an irregular bwoolly bodyQ appearance. These smears were all doubly read by two cytologists, as is the standard in our cytological laboratory. Actinomyces-positive women were questioned for any evidence of symptoms and signs suggestive of PID such as abdominal pain, fever and/or vaginal discharge. Bimanual pelvic examination was performed to rule out the presence of PID. Fornices tenderness, pelvic induration and adnexal swelling were taken as symptoms suggestive of pelvic inflammation. All women with positive smears had pelvic ultrasound examination to exclude presence of PID. In order to compare the treatment modalities for actinomyces-positive asymptomatic women, the 152 women with actinomyces-positive cervical smears were randomly allocated into four groups: Group 1 (25%) had no treatment; Group 2 was given penicillin V 500 mg three times a day for 2 weeks; Group 3 was given doxycycline 100 mg twice a day for 2 weeks; Group 4 was treated with metronidazole 400 mg three times a day for 2 weeks. The number of women in each group was 38. The choice of antibiotics was based on a literature search of current regimens used for the treatment of actinomycosis. All 152 women had follow-up visits at 3 and 6 months. History was taken at each visit for symptoms suggestive of PID. All had bimanual pelvic examination to look for signs suggestive of PID. Each woman had repeat cervical smears at each follow-up visit for ALO. Statistical analyses were performed using SPSS 12.0. The differences in evaluating the symptoms between treatment modalities were assessed using v 2 or Fisher’s Exact Test. Statistical significance was set at pb .05.
3.1. Incidence Cervical smears from 1108 IUCD users attending our Fertility Control Clinic were examined for the presence of actinomyces organisms. Among the 1108 IUCD users, 152 women were positive for actinomyces organisms, giving a prevalence rate of 13.7% (95% confidence interval, 11.8–15.9%). 3.2. Types of IUCD used Of the 152 women with actinomyces-positive smears, 52 women were using the Copper T, 50 were using the Multiload and 50 were using the Nova T (Table 1). No particular type of IUCD was specifically associated with the presence of actinomyces infection. The type of IUCD used did not appear to be an important risk factor. 3.3. Evidence of PID All 152 women with actinomyces-positive smears were asymptomatic. None had symptoms and signs suggestive of PID at the time of original confirmation. An ultrasound examination of the pelvis was done following detection of a positive actinomyces smear. In all 152 women, there was no evidence of any PID on ultrasound examination. 3.4. Modality of treatment None of the 38 women in the control or bno-treatmentT group showed any symptoms or signs of PID on follow-up. At 3 months’ follow-up, the smear in 17 out of 38 (44.7%) women showed absence of actinomyces organisms. At 6 months, 24 out of 38 (63.2%) women showed no evidence of actinomyces organisms. None of the 38 women in this group had removal of the IUCD. In the group who received penicillin V treatment, 16 out of 38 (42.1%) women showed absence of actinomyces organisms at the 3 months’ follow-up; the number increased to 23 (60.5%) at the 6 months’ follow-up. One woman in this group presented with increased vaginal discharge and abdominal pain at 5 months following the finding of actinomyces-positive smear. Clinical and ultrasound examination confirmed the presence of PID. Her IUCD was removed and she was treated effectively with other antibiotics for PID. Of the 38 women on doxycycline treatment, 15 (39.5%) had smears negative for actinomyces organism at 3 months. Table 2 Actinomyces-negative cervical smears at 3 months’ follow-up Type of treatment
No. of actinomyces-negative smears at 3 months’ follow-up (%)
Values of p as compared to control group
No treatment (n = 38) Penicillin V (n = 38) Doxycycline (n = 38) Metronidazole (n = 38)
17 16 15 19
1.000 .815 .490
(44.7) (42.1) (39.5) (50.0)
354
V. Kalaichelvan et al. / Contraception 73 (2006) 352 – 355
Table 3 Actinomyces-negative cervical smears at 6 months’ follow-up Type of treatment
No. of actinomyces-negative smears at 6 months’ follow-up (%)
Values of p as compared to control group
No treatment (n = 38) Penicillin V (n = 38) Doxycycline (n = 38) Metranidazole (n = 38)
24 23 22 21
.830 .639 .484
(63.2) (60.5) (57.9) (55.3)
The number increased to 22 (57.9%) at 6 months’ followup. One woman in this group presented with symptoms and signs of PID at her 6 months’ follow-up. Ultrasound showed normal findings. Nevertheless, her IUCD was removed and she was treated effectively for PID. Another woman had her IUCD removed at 6 months for personal reasons. In the group treated with metronidazole, 19 out of 38 (50.0%) women had cervical smears negative for actinomyces organism at 3 months. At 6 months, 21 out of 38 (55.3%) smears were negative. None of the women in this group had symptoms and signs suggestive of PID. There were no removals of IUCDs in this group. When the three treatment groups were compared to the control/no treatment group, there was no significant difference noted in the reduction of actinomyces-positive smears at 3 months (Table 2) and 6 months (Table 3) followup, respectively. 3. Discussion The IUCD is an effective contraceptive method and has the unique advantage of being a one-time reversible method with minimum side effects and no user compliance. However, its usage has been associated with increased incidence of vaginal infection and PID. Genital actinomyces was thought to be rare but has recently been reported with increasing frequency in association with IUCD use [1–4]. The literature suggests that the incidence of actinomycespositive cervical smears range from 1.6% to 44% [1–6]. Part of this variability can be explained by different levels of stringency applied in the evaluation of cervical smears, and possibly misinterpretation. In our study, the prevalence of actinomyces-positive cervical smear among IUCD users was 13.7%. Differing rates of colonization with actinomyces have been reported with the use of different types of IUCDs. Copper-containing IUCDs have been reported to have lower rates of colonization with A. israelii compared with other IUCDs [1]. In the present analysis, we were not able to find any difference between the presence of actinomyces organism and the type of IUCD [2,5,6]. The incidence of actinomyces positive cervical smear was similar with Copper T, Multiload and Nova T IUCDs in our study. Curtis and Pine [5] found that the chance of colonization with actinomyces increases with the duration of the use of an IUCD. There appears to be a direct relationship between the duration of IUCD usage and the development of actinomyces
infection [5,6]. In our study, we found no significant association between the duration of use of IUCD with regard to the incidence of ALO in cervical smears (data not shown). It is reported in the literature that the majority of IUCD users having actinomyces-positive smears are asymptomatic. In our study, 150 out of 152 (98.7%) IUCD users with actinomyces-positive smears were asymptomatic. The low incidence of endometriosis and salpingitis detected supports the view that A. israelii spreading from a colonization during IUCD use to infect the endometrium and further spread to the fallopian tubes causing symptomatic pelvic infection is not common, and if it does occur, it may be related to conditions where there is a specific preceding tissue damage [1,2]. The management of women with actinomyces-positive smears in the absence of significant symptoms is unsettled. It ranges from leaving the device in situ with no treatment, treatment with antimicrobials without removal of the IUCD, to removal of the IUCD in both symptomatic and asymptomatic women followed by antimicrobial treatment. Gupta et al. [6] and Luff and Gupta [7] recommended simple removable of the IUCD in both asymptomatic and symptomatic women, with the use of antibiotics only in symptomatic women. Garland and Rawling [8] recommended removal of the IUCD in both asymptomatic and symptomatic women and treatment of all colonized women with penicillin V. The current view of the American College of Obstetricians and Gynecologists and the Royal Australia and New Zealand College of Obstetricians and Gynecologists is that the IUCD need not be removed in asymptomatic women with actinomyces-positive smears [9–11]. Furthermore, in the absence of confirmation of pelvic infection by cultures, there is no need to treat such asymptomatic women with positive actinomyces smears [7,8]. In the present study, we have shown that only 2 out of 152 (1.3%) women with actinomyces-positive cervical smear developed PID at 6 months’ follow-up with the majority (98.7%) remaining asymptomatic. The results of our large perspective study suggest that there is no necessity to treat with antibiotics asymptomatic IUCD users who have actinomyces-positive cervical smears at follow-up. 5. Conclusion This study suggests that removal of the IUCD in asymptomatic women with actinomyces-positive cervical smears is not necessary. Moreover, we suggest that asymptomatic women with actinomyces-positive cervical smears do not require treatment with antibiotics. References [1] Sandra M, Oosterhof H, Van Dissel JP. Letter to editor: actinomyces and the intrauterine device. Arch Intern Med 1998; 158:1270.
V. Kalaichelvan et al. / Contraception 73 (2006) 352 – 355 [2] Charnock Chamber TJ. Pelvic actinomycosis and intrauterine contraceptive devices. Lancet 1970;1239 – 40. [3] Florino AS. Review — IUCD associated actinomycotic abscess and actinomyces detection on cervical smear. Obstet Gynaecol 1996;87: 142 – 9. [4] Cleghorn AG, Wilkinson RG. The IUCD associated incidence of Actinomyces israelii in the female genital tract. Aust N Z J Obstet Gynaecol 1989;29(4):445 – 9. [5] Curtis EM, Pine L. Actinomyces in the vagina of women with and without intrauterine contraceptive devices. Am J Obstet Gynecol 1981;140:880 – 4. [6] Gupta PK, Hollender DH, Frost JK. Actinomyces in cervical–vaginal smears: an association with IUD usage. Acta Cytologica 1976;20: 295 – 7.
355
[7] Luff RD, Gupta PK. Actinomyces-like organisms in wearers of intrauterine contraceptive devices. Am J Obstet Gynecol 1977;129: 476 – 7. [8] Garland SM, Rawling D. Pelvic actinomycosis in association with intrauterine device. Aust N Z J Obstet Gynaecol 1993;33:96 – 8. [9] Royal Australian and New Zealand College of Obstetricians and Gynaecologists Intrauterine Contraceptive Devices and Infection. C-Gyn 3, 2003. [10] IPPF. Medical advisory panel statement on intrauterine devices. IPPF Med Bull 1995;29:6. [11] Hager WD, Majmudar B. Pelvic actinomycosis in women using intrauterine contraceptive devices. Am J Obstet Gynecol 1979;133: 60 – 3.