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Three Part Question

In [women diagnosed with PID and with an IUD in place] is [immediate removal of the IUD along with appropriate antibiotic treatment] beneficial in [reducing the length of symptoms and reducing the rate of recurrence]?

Clinical Scenario

A 26-year-old woman presents to the Emergency Department with pelvic pain and purulent vaginal discharge is diagnosed with pelvic inflammatory disease (PID). She had an intrauterine device (IUD) placed six months ago after the birth of her third child. She is afebrile, able to tolerate oral intake, and can be managed as an outpatient. As you discharge her with antibiotics, you wonder if you should have removed the IUD or arrange to have it removed by her gynecologist.

Search Strategy

PubMed was searched using the following terms : (Removal intrauterine device pelvic inflammatory disease), AND (coil removal treatment pelvic inflammatory disease) limited to human, English, meta analysis, and review.
Specialty guidelines were reviewed, as well as each article’s references were reviewed for further relevant citations. 208 articles were found and 4 of those specifically addressed the 3 part question.

Search Outcome

Farley et al. looked at the use of IUD internationally and found that the risk of PID was highest in the first three weeks post-insertion and was likely related to the insertion method and the patient’s background risk of STD. The article noted that the risk was low and constant for up to eight years after that. Grimes et al performed a systematic review and showed that in the presence of cervicitis, an IUD user (in fact, even one with known HIV) does not have a higher risk of salpingitis than a person without an IUD. If PID does occur after the first 3 weeks, it is most likely from a newly acquired STD. In most cases, IUDs are placed only in prescreened women who are in long-standing monogamous relationships making the risk of an STD less likely. Neither of the two common types of IUDs have been shown to increase the risk of PID, the levonorgestrel IUD has a lower risk of PID because of the effects of progestin on the cervical mucus. PID does, however, occur in this population, and while it seems reasonable to take out the IUD (which may be harboring infection), there are few studies about treatment in this population of patients and little is known about the risk of recurrence if the IUD is left in place.

When PID does occur in IUD users, it is typically polymicrobial, involving anaerobic bacteria from the cervix and vagina. If you suspect PID, common antibiotic regimens (outpatient or inpatient) should be initiated whether or not the IUD is removed. Treatment options are the same as for the non-IUD user.
Only several studies have evaluated the role of IUD removal in the treatment of PID. Teisala performed a retrospective study to investigate the effect of removal of an IUD on the response to antimicrobial treatment of acute PID. All patients were hospitalized and treated with IV antibiotics. The study determined that there was no difference in the short- term recovery between patients who had an IUD in place versus those who had it removed. Interestingly, those who had the IUD removed, had a longer hospital stay. Altunyurt et al. performed a randomized controlled trial of coil removal prior to treatment of PID. All patients were treated as outpatients with oral antibiotics consisting of ciprofloxacin, metronidazole and doxycycline. The study determined that coil removal prior is not extremely necessary before initiating treatment for PID however it showed that women who had the coil removed did have significant benefits to include faster improvement of pelvic pain and vaginal discharge. Soderberg and Lindgren performed a prospective study looking at the influence of an IUD on acute salpingitis and found that early removal of the IUD did not influence the course of the disease. Larsson and Wennergren performed a retrospective study to determine if the removal of a copper IUD has any effect on recovery from PID. This study determined that copper IUD removal offers no advantage to in-patients being treated for PID. The study also concluded that keeping the IUD in place does not increase the rate of recurrence or alter the rate of pregnancies compared to patients who had the IUD removed. The CDC’s report on the management of the treatment of PID states that there is insufficient evidence to support removal of the IUD, but close follow up and monitoring are necessary. The WHO also issued a statement that the IUD does not have to be removed if the risk of removal outweighs the risk of leaving the IUD in place.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Teisala 1989 Finland	186 women with IUDs admitted for acute PID	Retrospective Study	Effect of removal of an IUD on the response to antimicrobial treatment.	No significant difference	Small numbers
Altnunyurt S, et al 2003 Turkey	138 women with clinically diagnosed mild-to-moderate PID were randomized to IUD removal before treatment vs. treatment alone All patients treated with ciprofloxacin 500 mg/day plus metronidazole 500 mg/day plus doxycycline 100 mg/day orally for 14 days with follow-up exam on day 15	Randomized control trial	Recovery rates Treatment failure, improvement in clinical symptoms	IUD removal was not absolutely necessary however patients that had it removed showed faster improvement of some symptoms including vaginal discharge and pelvic pain.	High number patients lost to follow up
Larsson, Winnergren 1977 Sweden	928 in-patients treated for PID. Patients were divided into 3 groups. Group1: 632 women who never had an IUD Group 2: 236 women who had IUD left in situ Group 3: 60 women who had the IUD removed	Retrospective Study	Length of hospital stay Secondary outcomes: Recurrence rate of PID Subsequent pregnancies	Removal of the IUD offers no advantage to inpatients being treated for PID There was no significant difference between groups regarding the incidence of recurrence or number of subsequent pregnancies	Although it was a somewhat large study, it was retrospective.

Comment(s)

DISCLAIMER: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense or the United States Government.

Clinical Bottom Line

IUD removal is not required in patients being treated for PID. Removal does not decrease the rate of recurrence or lengthen symptoms of PID. The antibiotic regimen for patients with an IUD should be the same as those without an IUD in place.

References

1. Teisala K. Removal of an intrauterine device and the treatment of acute pelvic inflammatory disease. Ann Med 1989 Feb;21(1):63-5
2. Altunyurt S, Demir N, Posaci C. A randomized control trial of coil removal prior to treatment of pelvic inflammatory disease. Eur J Obstet Gynecol Reprod Biol 2003; 107.81
3. Soderberg G, Lindgren S. Influence of an Intrauterine Device on the Course of an Acute Salpingitis. Contraception Aug 1981 Vol.24 No.2
4. Larsson B, Wennergren M. Investigation of a Copper – Intrauterine Device (Cu-IUD) for possible Effect on Frequency and Healing of Pelvic Inflammatory Disease. Contraception Feb1977Vol.15No.2
5. Farley TM. Rosenberg MJ. Rowe PJ et al. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet. 1992;339(8796):785-8
6. Grimes DA, Lopez LM, Schulz KF. Antibiotic prophylaxis for intrauterine contraceptive device insertion Cochrane Database of Systematic Reviews 1999, Issue 3. Art. No.: CD001327. DOI: 10.1002/14651858.CD001327.
7. Centers for Disease Control and Prevention (CDC). Treatment Guidelines.[Online] Pelvic Inflammatory Disease CDC 2010. http://www.cdc.gov/std/treatment/2010/pid.htm (accessed 17th Oct 2011)