- Email: [email protected]
Bacterial flora of the cervix in women using an intrauterine device
CONTRACEPTION
BACTERIAL
IN WOMEN USING AN INTRAUTERINE
FLORA OF THE CERVIX
DEVICE
M. Haukkamaa, M.D.* P. Stranden, M.S. H. Jousimies-Somer, M.S. A. Siitonen, M.S.
*Helsinki Maternity Hospital; Steroid Research Laboratory, Department Medical Chemistry, University of Helsinki, Helsinki, Finland The
Anaerobe Reference Unit and the Enterobacterial Reference National Public Health Institute, Helsinki, Finland
of
Laboratory,
ABSTRACT The cervical bacterial flora of 18 healthy, parous, sexually active women was analysed before, and 3 - 5 months after insertion of a copperreleasing intrauterine device (IUD) and after long-term use of an IUD for 35.5 years in another nine women. No significant differences were found in the number of aerobic bacteria isolated before or after IUD insertion or after In contrast to aerobic bacteria, long-term use of an IUD. significantly more anaerobes were isolated in the cervix of women having used an IUD for several years when compared to those using barrier contraception withacondom. None of the women had clinical signs of pelvic infection and a cervical bacterial flora rich in anaerobes can be regarded as a normal finding in healthy sexually active women using an IUD for contraception.
Reprint
requests:
Dr. Maija Haukkamaa, M.D. Steroid Research Laboratory Department of Medical Chemistry University of Helsinki Siltavuorenpenger 10 A SF-00170 Helsinki Finland
Submitted for publication October Accepted for publication November
NOVEMBER
28, 1987 9, 1987
1987 VOL. 36 NO. 5
527
CONTRACEPTION
INTRODUCTION It is well known that use of an intrauterine device (IUD) increases the risk of pelvic inflammatory disease (PID) (1, 2, 3, 4). The increased risk is especially related to age under 25 years, whereas parity has less effect In young women using an IUD, the increased risk of PID has been (2, 4). supposed to be related to increased sexual activity and multiple partners. Analysis of tubal infertility and use of an IUD revealed that women with only one partner and,a copper-releasing modern type of IUD only had a minor increase in relative risk of infection (5). The relative risk of tubal infertility was increased with multiple sexual partners, showing that the copper-releasing IUD is safe in appropriately selected women. It is also evident that tubal infertility is largely a consequence of "silent" chlamydial infections (6), whereas use of an IUD is not the primary reason an IUD offers no protection against infection, for tubal damage. However, in contrast to oral contraceptives which have a protective effect (4, 7). Most bacteriological studies have been performed in patients with acute infection, whereas normal states have received less attention. The ascending nature of acute salpingitis means that cervical bacteria may be This led us to study the normal of importance in the aetiology of PID. bacterial flora of the cervix of healthy sexually active women using a aim of the present study was to observe copper-releasing IUD. Another possible changes in the cervical flora during short-term and long-term use of an IUD. It was suspected that the occurrence of potential pathogens might be increased during use of an IUD.
MATERIALS
AND METHODS
Women attending the outpatient clinic of Helsinki Maternity Patients. Helsinki, Finland, volunteered for the study. To nine women aged Hospital, Nova-T (Leiras 19 - 35 years a copper-releasing intrauterine device, Pharmaceuticals, Turku, Finland), was inserted postmenstrually in the usual A second group of nine women aged 23 - 43 years way with tails visible. received the same Nova-T in postmenstrum but the tails were cut short and the IUD was inserted with shortened tails bent upwards in the uterine cavity. The women had been randomised before IUD insertion. Nine women having used a Nova-T for at least three years (range 3 - 5.5 years), aged represented a group of test subjects with long-term use of 33 - 46 years, In routine All women were parous and healthy. the same device. gynaecological examination no evidence of vaginal or cervical infection was noted. Sexual activity was ascertained by asking the day of last sexual Antimicrobial agents had not been taken during intercourse at each visit. At the first control visit after IUD insertion, the preceding month. invisible IUD tails to sonography was performed in those women with ascertain that the IUDs were in place. The visits took place in the luteal Bacteriological and other samples. Before IUD insertion, when all samples were taken. phase of the cycle, bacteriological and other samples were taken in the preceding cycle, during The women thus served as their own barrier contraception with a condom. After IUD insertion the next control visit controls before use of the IUD. when control culture samples were took place 3 - 5 months after insertion,
NOVEMBER
1987 VOL. 36 NO. 5
CONTRACEPTION
In addition to gynaecological examination, the following samples taken. a sample for bacteriological culture from the cervix, a were taken: Trichomonas vaginalis and culture sample for Candida albicans (yeasts), A cervicovaginal Papanicolau smear and a potassium Chlamydia trachomatr hydroxide test for amine odour were also performed. The bacteriological samples were processed within two hours at the Anaerobic Reference Unit of Finland. The methods of the National Public Health Institute. Helsinki. bacterial culture have been described in detaii previously (8). Poisson's of numbers of bacteria t test was used for statistical calculation isolated. RESULTS examination of the women The routine samples taken and gynaecological that the showed that all were free of pelvic inflammatory disease (PID) and _ __ isolates could be regarded as part of the normal flora ot bacteriological None of the cervicovaginal smears showed healthy sexually active women. all cultures for Chlamydia trachomatis were negative and no atypia, In addition, gonococci were not isolated. Trichomonas vaginalis was found. Yeasts were found on ten visits out of 45 and some of these patients were The potassium hydroxide odour test treated although they had no symptoms. was positive in one patient in each group and this positive test was associated with the isolation of several anaerobic bacteria in the cervix of these women. The number of aerobic and anaerobic isolates in the cervix of the women The total number of in the three study groups are shown in Table I. bacteria isolated increased with use of the IUD. The highest number of total isolates was found in those having used an IUD for at least three (p
DISCUSSION The present results confirm the already known fact that a lactobacillidominated cervical flora is maintained if a condom is used for contraception (8). Before insertion of an IUD only occasional potential
NOVEMBER 1987 VOL. 36 NO. 5
CONTRACEPTION
Table
I.
Number of different types of aerobes and anaerobes isolated from groups of nine women before and after insertion of an IUD
Tail in uterine cavity
Tail visible
Before insertion
After insertion
Before insertion
After insertion
10
20
14
22
15
16**
21
48* **
30
43
63
Aerobes Anaerobes Total
6*
7
16
27
Long-term use of IUD
* p
Table II. Aerobic bacteria isolated from groups of nine women before insertion of an IUD, 3 - 5 months after insertion and after long-term IUD use of 3 - 5.5 years
Tail in uterine cavity Before insertion
After insertion
Tail visible Before insertion
Long-term use of IUD
After insertion
Gram-positive cocci Staphylococcus aureus Coagulase-negative staphylococci Viridans streptococci Microaerophilic streptococci Group B streptococci Enterococci
1 1 4
1
3 2
1
2 1
2
1
2
1
8
1;
:
:
2
1 3
4
Gram-positive rods Corynebacterium sp. Lactobacillus sp.
:
Gram-negative rods Eikenella corrodens Escherichia coli Gardnerella vaginalis
530
1
1
NOVEMBER
1 3
1987 VOL. 36 NO. 5
CONTRACEPTION
Table III. Anaerobic bacteria isolated from groups of nine women before insertion of an IUD, 3 - 5 months after insertion and after long-term IUD use of 3 - 5.5 years Tail in uterine cavity Before insertion
After insertion
Tail visible Before insertion
Long-term use of IUD
After insertion
Gram-positive cocci Peptostreptococcus anaerobius P. asaccharolyticus P. magnus P. micros P. prevotii P. tetradius Peptostreptococcus sp. Gram-positive rods Actinomyces israelii Actinomyces meyeri Actinomyces odontolyticus Arachnia propionica Bifidobacterium sp. Clostridium ramosum Eubacterium sp. Lactobacillus sp. Propionibacterium acnes
2
1
1
1 1 11 2
4
Gram-negative cocci 1
Veillonella parvula Gram-negative rods Bacteroides asaccharolyticus B. bivius B. buccae B. corporis B. disiens B. fragilis B. gracilis B. intermedius B. loescheii B. melaninogenicus B. oralis Bacteroides sp. Fusobacterium nucleatum Mobiluncus sp.
1 1
NOVEMBER 1987 VOL. 36 NO. 5
2
2
1
1
2
2 1 1 2 1 1 1 1
1 3
1 2 2 1 1 1 1 3 1
531
CONTRACEPTION
such as enterococci, group B pathogens streptococci or Gardnerella vaginalis and a few anaerobic bacteria were isolated, whereas long-term use of an IUD was associated with significantly increased amounts of anaerobes in the cervix (8). Such an anaerobic shift has also been noted during contraception with oral contraceptives (8) showing that sexual activity as The male factor may have significance in the increased such is important. Toth -et al. risk of PID in users of an IUD, as in other women. (9) suggested a causal role for spermatozoa in the carriage of bacteria to Asymptomatic bacteriospermia has been found in the female genital tract. fertile and infertile men (10) and the severity of bacteriospermia was related to the number of prior sexual partners. the possible However, connection between the anaerobic shift found in the cervical flora and the male factor has not been studied. studies of patients with acute salpingitis, a In microbiological polymicrobial pathogenic endocervical flora has been found both in gonococcal and non-gonococcal acute salpingitis (11). Significantly more anaerobic bacteria were isolated from the endocervical canal of patients either lower genital tract infection or salpingitis. with acute Lactobacilli dominated in those with no clinical infection. The spectra of bacteria isolated in our patients with and without an IUD were similar. Increased amounts of anaerobes may reflect an increased risk of upper genital tract infection. A rich anaerobic flora gives symptoms and clinical which should be actively treated. In findings of bacterial vaginosis (12), those with recurrent infections, liberal removal of IUDs is recommended. Identification of risk groupsforacute salpingitis (11) is similar to IUD: young identification of risk patients for PID during the use of an age, single, urban, nulliparous, multiple sexual partners, induced abortion or and especially PID in medical history. Hormonal methods of contraception barrier methods must be favoured in these women. Thus,they can be best protected against tubal damage and subsequent infertility or extrauterine pregnancy. The role of the tail in IUD-related infections is still controversial (13). In a recent study with copper IUDs, more infections were found with in this report the criteria of infection and tails visible (14). However, removal because of infection were not stated. It is easier to remove an IUD with a tail whereas an invisible tail always needs skilled doctors and good facilities for removal. Large randomised patient series are needed to solve in particular because the infection rates with appropriate this question, patient selection are low at present (15). Recently,the reputation of the IUD has become better, particularly after it became evident that infections with Chlamydia trachomatis are partly responsible for tubal damage and subsequent extrauterine pregnancy (6, 16). Sexual behaviour is as important as the contraceptive methods used. It should be kept in mind that no protection against infection is provided by an IUD, whereas oral contraceptives offer some protection (17). Patient selection is therefore essential before IUD insertion. during long-term use of an IUD, increased numbers of In conclusion, This anaerobic bacteria were found in the cervical flora of healthy women. finding may be associated with the increased risk of PID and anaerobic vaginosis during IUD use.
NOVEMBER
1987 VOL.
36 NO. 5
CONTRACEPTION
ACKNOWLEDGMENTS This study was supported
by the Paulo
Foundation,
Helsinki,
Finland.
REFERENCES
1.
Westt-iim, L., Bengtsson, L.P., disease in women inflammatory devices as compared to non-users.
2.
Booth, M., inflammatory intrauterine
3.
Burkman, R.T. Women's health device and pelvic inflammatory (1981)
4.
Task Force on Intrauterine Devices, Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization. PID associated with fertility regulating agents. Contraception 30: 1-21 (1984)
5.
Cramer, D.W., Schiff, I., Schoenbaum, S.C. & al. Tubal and the intrauterine device. N. Engl. J. Med. 312: 941-947
6.
Guderian, A.M., Trobough, G.E. Residues of pelvic inflammatory disease in intrauterine device users: A result of the intrauterine device or Chlamydia trachomatis infection? Am. J. Obstet. Gynecol. 154: 497-503 (1986)
7.
Senanayake, P., Kramer, D.G. Contraception pelvic inflammatory disease: new perspectives. 138: 852-860 (1980)
8.
Haukkamaa, M., Stranden, P., Jousimies-Somer, H., Siitonen, Bacterial flora of the cervix in women using different methods contraception. Am. J. Obstet. Gynecol. 154: 520-524 (1986)
9.
Toth, A., O'Leary, transfer by spermatozoa.
10.
Toth, A., and infertile
11.
Kinghorn, G.R., Duerden, B.I., Hafiz, S. Clinical and microbiological investigation of women with acute salpingitis and their consorts. Br. J. Obstet,. Gynecol. 93: 869-880 (1986)
12.
KivijLrvi, vaginitis
J. Obstet.
Msrdh, P.D. The risk of pelvic using intrauterine contraceptive Lancet 2: 221-224 (1976)
Beral V.A., Guillebaud, J. Effect of age on pelvic disease in nulliparous women using a Copper 7 contraceptive device. Br. Med. J. 281: 114 (1980) study. Association disease. Obstet.
between intrauterine Gynecol. 57: 269-276
infertility (1985)
and the ethiology of Am. J. Obstet. Gynecol.
W., Ledger, W. Evidence for microbial Obstet. Gynecol. 59: 556-559 (1982)
Lesser, M. Asymptomatic bacteriospermia men. Fertil. Steril. 36: 88-91 (1981)
in
fertile
A., JBrvinen, H., Grdnroos, M. Microbiology associated with the intrauterine contraceptive device.
Gynecol.
A. of
91: 917-923
(1984)
NOVEMBER 1987 VOL. 36 NO. 5
of
Br
533
CONTRACEPTION
13.
Wheeler, R.G., Cole, L.P., Galvez, R.S. strings. In: Intrauterine Contraception: Prospects (Zatuchni, G.I., Goldsmith, A., Harper & Row, Philadelphia, 1984, pp. 420-426.
14.
Batar, I., Lampe, L., Allonen, H. IUD and PID - a two year comparative study of copper-silver devices inserted with and without tail. In: Advances in contraceptive Delivery systems. C.D.S. International Symposium Genetics of Fertility Regulation, Nairobi, Kenya, September 22-25, 1985, pp. 355.
15.
Luukkainen, ~ova-~'~~d
IUDs with Advances Sciarra,
or without and Future J.J., eds).
T.,
Allonen, H., Nielsen, N.-C., Nygren, K.-G.. PySrll~, experience of intrauterine contraception with C~~~$T-200. Am. J. Obstet. Gynecol. 147: 885-892 (1983)
16.
Jones, R.B., Ardery, B.R., Hui, S.L., Cleary, R.E. Correlation between serum antichlamydial antibodies and tubal factor as a cause of infertility. Fertil. Steril. 38: 553-558 (1982)
17.
Keith, L.G., Berger, G.S. The pathogenic infection. In: Intrauterine Contraception: Prospects (Zatuchni, G.I., Goldsmith, A., Harper & Row, Philadelphia, 1984, pp. 450-471.
534
NOVEMBER
mechanisms of Advances and Sciarra, J.J.,
pelvic Future eds).
1987 VOL. 36 NO. 5
BACTERIAL
IN WOMEN USING AN INTRAUTERINE
FLORA OF THE CERVIX
DEVICE
M. Haukkamaa, M.D.* P. Stranden, M.S. H. Jousimies-Somer, M.S. A. Siitonen, M.S.
*Helsinki Maternity Hospital; Steroid Research Laboratory, Department Medical Chemistry, University of Helsinki, Helsinki, Finland The
Anaerobe Reference Unit and the Enterobacterial Reference National Public Health Institute, Helsinki, Finland
of
Laboratory,
ABSTRACT The cervical bacterial flora of 18 healthy, parous, sexually active women was analysed before, and 3 - 5 months after insertion of a copperreleasing intrauterine device (IUD) and after long-term use of an IUD for 35.5 years in another nine women. No significant differences were found in the number of aerobic bacteria isolated before or after IUD insertion or after In contrast to aerobic bacteria, long-term use of an IUD. significantly more anaerobes were isolated in the cervix of women having used an IUD for several years when compared to those using barrier contraception withacondom. None of the women had clinical signs of pelvic infection and a cervical bacterial flora rich in anaerobes can be regarded as a normal finding in healthy sexually active women using an IUD for contraception.
Reprint
requests:
Dr. Maija Haukkamaa, M.D. Steroid Research Laboratory Department of Medical Chemistry University of Helsinki Siltavuorenpenger 10 A SF-00170 Helsinki Finland
Submitted for publication October Accepted for publication November
NOVEMBER
28, 1987 9, 1987
1987 VOL. 36 NO. 5
527
CONTRACEPTION
INTRODUCTION It is well known that use of an intrauterine device (IUD) increases the risk of pelvic inflammatory disease (PID) (1, 2, 3, 4). The increased risk is especially related to age under 25 years, whereas parity has less effect In young women using an IUD, the increased risk of PID has been (2, 4). supposed to be related to increased sexual activity and multiple partners. Analysis of tubal infertility and use of an IUD revealed that women with only one partner and,a copper-releasing modern type of IUD only had a minor increase in relative risk of infection (5). The relative risk of tubal infertility was increased with multiple sexual partners, showing that the copper-releasing IUD is safe in appropriately selected women. It is also evident that tubal infertility is largely a consequence of "silent" chlamydial infections (6), whereas use of an IUD is not the primary reason an IUD offers no protection against infection, for tubal damage. However, in contrast to oral contraceptives which have a protective effect (4, 7). Most bacteriological studies have been performed in patients with acute infection, whereas normal states have received less attention. The ascending nature of acute salpingitis means that cervical bacteria may be This led us to study the normal of importance in the aetiology of PID. bacterial flora of the cervix of healthy sexually active women using a aim of the present study was to observe copper-releasing IUD. Another possible changes in the cervical flora during short-term and long-term use of an IUD. It was suspected that the occurrence of potential pathogens might be increased during use of an IUD.
MATERIALS
AND METHODS
Women attending the outpatient clinic of Helsinki Maternity Patients. Helsinki, Finland, volunteered for the study. To nine women aged Hospital, Nova-T (Leiras 19 - 35 years a copper-releasing intrauterine device, Pharmaceuticals, Turku, Finland), was inserted postmenstrually in the usual A second group of nine women aged 23 - 43 years way with tails visible. received the same Nova-T in postmenstrum but the tails were cut short and the IUD was inserted with shortened tails bent upwards in the uterine cavity. The women had been randomised before IUD insertion. Nine women having used a Nova-T for at least three years (range 3 - 5.5 years), aged represented a group of test subjects with long-term use of 33 - 46 years, In routine All women were parous and healthy. the same device. gynaecological examination no evidence of vaginal or cervical infection was noted. Sexual activity was ascertained by asking the day of last sexual Antimicrobial agents had not been taken during intercourse at each visit. At the first control visit after IUD insertion, the preceding month. invisible IUD tails to sonography was performed in those women with ascertain that the IUDs were in place. The visits took place in the luteal Bacteriological and other samples. Before IUD insertion, when all samples were taken. phase of the cycle, bacteriological and other samples were taken in the preceding cycle, during The women thus served as their own barrier contraception with a condom. After IUD insertion the next control visit controls before use of the IUD. when control culture samples were took place 3 - 5 months after insertion,
NOVEMBER
1987 VOL. 36 NO. 5
CONTRACEPTION
In addition to gynaecological examination, the following samples taken. a sample for bacteriological culture from the cervix, a were taken: Trichomonas vaginalis and culture sample for Candida albicans (yeasts), A cervicovaginal Papanicolau smear and a potassium Chlamydia trachomatr hydroxide test for amine odour were also performed. The bacteriological samples were processed within two hours at the Anaerobic Reference Unit of Finland. The methods of the National Public Health Institute. Helsinki. bacterial culture have been described in detaii previously (8). Poisson's of numbers of bacteria t test was used for statistical calculation isolated. RESULTS examination of the women The routine samples taken and gynaecological that the showed that all were free of pelvic inflammatory disease (PID) and _ __ isolates could be regarded as part of the normal flora ot bacteriological None of the cervicovaginal smears showed healthy sexually active women. all cultures for Chlamydia trachomatis were negative and no atypia, In addition, gonococci were not isolated. Trichomonas vaginalis was found. Yeasts were found on ten visits out of 45 and some of these patients were The potassium hydroxide odour test treated although they had no symptoms. was positive in one patient in each group and this positive test was associated with the isolation of several anaerobic bacteria in the cervix of these women. The number of aerobic and anaerobic isolates in the cervix of the women The total number of in the three study groups are shown in Table I. bacteria isolated increased with use of the IUD. The highest number of total isolates was found in those having used an IUD for at least three (p
DISCUSSION The present results confirm the already known fact that a lactobacillidominated cervical flora is maintained if a condom is used for contraception (8). Before insertion of an IUD only occasional potential
NOVEMBER 1987 VOL. 36 NO. 5
CONTRACEPTION
Table
I.
Number of different types of aerobes and anaerobes isolated from groups of nine women before and after insertion of an IUD
Tail in uterine cavity
Tail visible
Before insertion
After insertion
Before insertion
After insertion
10
20
14
22
15
16**
21
48* **
30
43
63
Aerobes Anaerobes Total
6*
7
16
27
Long-term use of IUD
* p
Table II. Aerobic bacteria isolated from groups of nine women before insertion of an IUD, 3 - 5 months after insertion and after long-term IUD use of 3 - 5.5 years
Tail in uterine cavity Before insertion
After insertion
Tail visible Before insertion
Long-term use of IUD
After insertion
Gram-positive cocci Staphylococcus aureus Coagulase-negative staphylococci Viridans streptococci Microaerophilic streptococci Group B streptococci Enterococci
1 1 4
1
3 2
1
2 1
2
1
2
1
8
1;
:
:
2
1 3
4
Gram-positive rods Corynebacterium sp. Lactobacillus sp.
:
Gram-negative rods Eikenella corrodens Escherichia coli Gardnerella vaginalis
530
1
1
NOVEMBER
1 3
1987 VOL. 36 NO. 5
CONTRACEPTION
Table III. Anaerobic bacteria isolated from groups of nine women before insertion of an IUD, 3 - 5 months after insertion and after long-term IUD use of 3 - 5.5 years Tail in uterine cavity Before insertion
After insertion
Tail visible Before insertion
Long-term use of IUD
After insertion
Gram-positive cocci Peptostreptococcus anaerobius P. asaccharolyticus P. magnus P. micros P. prevotii P. tetradius Peptostreptococcus sp. Gram-positive rods Actinomyces israelii Actinomyces meyeri Actinomyces odontolyticus Arachnia propionica Bifidobacterium sp. Clostridium ramosum Eubacterium sp. Lactobacillus sp. Propionibacterium acnes
2
1
1
1 1 11 2
4
Gram-negative cocci 1
Veillonella parvula Gram-negative rods Bacteroides asaccharolyticus B. bivius B. buccae B. corporis B. disiens B. fragilis B. gracilis B. intermedius B. loescheii B. melaninogenicus B. oralis Bacteroides sp. Fusobacterium nucleatum Mobiluncus sp.
1 1
NOVEMBER 1987 VOL. 36 NO. 5
2
2
1
1
2
2 1 1 2 1 1 1 1
1 3
1 2 2 1 1 1 1 3 1
531
CONTRACEPTION
such as enterococci, group B pathogens streptococci or Gardnerella vaginalis and a few anaerobic bacteria were isolated, whereas long-term use of an IUD was associated with significantly increased amounts of anaerobes in the cervix (8). Such an anaerobic shift has also been noted during contraception with oral contraceptives (8) showing that sexual activity as The male factor may have significance in the increased such is important. Toth -et al. risk of PID in users of an IUD, as in other women. (9) suggested a causal role for spermatozoa in the carriage of bacteria to Asymptomatic bacteriospermia has been found in the female genital tract. fertile and infertile men (10) and the severity of bacteriospermia was related to the number of prior sexual partners. the possible However, connection between the anaerobic shift found in the cervical flora and the male factor has not been studied. studies of patients with acute salpingitis, a In microbiological polymicrobial pathogenic endocervical flora has been found both in gonococcal and non-gonococcal acute salpingitis (11). Significantly more anaerobic bacteria were isolated from the endocervical canal of patients either lower genital tract infection or salpingitis. with acute Lactobacilli dominated in those with no clinical infection. The spectra of bacteria isolated in our patients with and without an IUD were similar. Increased amounts of anaerobes may reflect an increased risk of upper genital tract infection. A rich anaerobic flora gives symptoms and clinical which should be actively treated. In findings of bacterial vaginosis (12), those with recurrent infections, liberal removal of IUDs is recommended. Identification of risk groupsforacute salpingitis (11) is similar to IUD: young identification of risk patients for PID during the use of an age, single, urban, nulliparous, multiple sexual partners, induced abortion or and especially PID in medical history. Hormonal methods of contraception barrier methods must be favoured in these women. Thus,they can be best protected against tubal damage and subsequent infertility or extrauterine pregnancy. The role of the tail in IUD-related infections is still controversial (13). In a recent study with copper IUDs, more infections were found with in this report the criteria of infection and tails visible (14). However, removal because of infection were not stated. It is easier to remove an IUD with a tail whereas an invisible tail always needs skilled doctors and good facilities for removal. Large randomised patient series are needed to solve in particular because the infection rates with appropriate this question, patient selection are low at present (15). Recently,the reputation of the IUD has become better, particularly after it became evident that infections with Chlamydia trachomatis are partly responsible for tubal damage and subsequent extrauterine pregnancy (6, 16). Sexual behaviour is as important as the contraceptive methods used. It should be kept in mind that no protection against infection is provided by an IUD, whereas oral contraceptives offer some protection (17). Patient selection is therefore essential before IUD insertion. during long-term use of an IUD, increased numbers of In conclusion, This anaerobic bacteria were found in the cervical flora of healthy women. finding may be associated with the increased risk of PID and anaerobic vaginosis during IUD use.
NOVEMBER
1987 VOL.
36 NO. 5
CONTRACEPTION
ACKNOWLEDGMENTS This study was supported
by the Paulo
Foundation,
Helsinki,
Finland.
REFERENCES
1.
Westt-iim, L., Bengtsson, L.P., disease in women inflammatory devices as compared to non-users.
2.
Booth, M., inflammatory intrauterine
3.
Burkman, R.T. Women's health device and pelvic inflammatory (1981)
4.
Task Force on Intrauterine Devices, Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization. PID associated with fertility regulating agents. Contraception 30: 1-21 (1984)
5.
Cramer, D.W., Schiff, I., Schoenbaum, S.C. & al. Tubal and the intrauterine device. N. Engl. J. Med. 312: 941-947
6.
Guderian, A.M., Trobough, G.E. Residues of pelvic inflammatory disease in intrauterine device users: A result of the intrauterine device or Chlamydia trachomatis infection? Am. J. Obstet. Gynecol. 154: 497-503 (1986)
7.
Senanayake, P., Kramer, D.G. Contraception pelvic inflammatory disease: new perspectives. 138: 852-860 (1980)
8.
Haukkamaa, M., Stranden, P., Jousimies-Somer, H., Siitonen, Bacterial flora of the cervix in women using different methods contraception. Am. J. Obstet. Gynecol. 154: 520-524 (1986)
9.
Toth, A., O'Leary, transfer by spermatozoa.
10.
Toth, A., and infertile
11.
Kinghorn, G.R., Duerden, B.I., Hafiz, S. Clinical and microbiological investigation of women with acute salpingitis and their consorts. Br. J. Obstet,. Gynecol. 93: 869-880 (1986)
12.
KivijLrvi, vaginitis
J. Obstet.
Msrdh, P.D. The risk of pelvic using intrauterine contraceptive Lancet 2: 221-224 (1976)
Beral V.A., Guillebaud, J. Effect of age on pelvic disease in nulliparous women using a Copper 7 contraceptive device. Br. Med. J. 281: 114 (1980) study. Association disease. Obstet.
between intrauterine Gynecol. 57: 269-276
infertility (1985)
and the ethiology of Am. J. Obstet. Gynecol.
W., Ledger, W. Evidence for microbial Obstet. Gynecol. 59: 556-559 (1982)
Lesser, M. Asymptomatic bacteriospermia men. Fertil. Steril. 36: 88-91 (1981)
in
fertile
A., JBrvinen, H., Grdnroos, M. Microbiology associated with the intrauterine contraceptive device.
Gynecol.
A. of
91: 917-923
(1984)
NOVEMBER 1987 VOL. 36 NO. 5
of
Br
533
CONTRACEPTION
13.
Wheeler, R.G., Cole, L.P., Galvez, R.S. strings. In: Intrauterine Contraception: Prospects (Zatuchni, G.I., Goldsmith, A., Harper & Row, Philadelphia, 1984, pp. 420-426.
14.
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1987 VOL. 36 NO. 5