Do contraceptives offer protection against PID?
Is the use of popular forms of birth control — including oral contraceptives (OCs) — associated with a protective effect against pelvic inflammatory disease (PID)? Findings from a just-published study indicate that use of OCs, depot medroxyprogesterone acetate (DMPA) injections, and barrier methods, including condoms, do not reduce a woman’s risk for the sexually transmitted disease (STD).1
The University of Pittsburgh-led study analyzed contraceptive use among 563 women who had signs and symptoms of PID and who were enrolled in the PID Evaluation and Clinical Health (PEACH) Study, a randomized clinical treatment trial. Participants were between ages 14 and 37 and were recruited from emergency departments, clinics, and STD clinics at each of 13 sites. The PEACH study was designed as a randomized clinical trial to evaluate the effectiveness of inpatient vs. outpatient treatment of PID, explains lead author Roberta Ness, MD, MPH, associate professor of epidemiology, medicine, and OB/GYN at the University of Pittsburgh. Other findings from the study have been published previously.2-4
Each women in the study was interviewed, examined, and received an endometrial biopsy and upper genital tract isolate microbiologic evaluation. Condoms were the most common method of contraception used, followed by OCs, DMPA injections, and other barrier methods.
Investigators found that neither recent oral contraceptive use nor barrier method use (condoms or other barrier methods) reduced the risk of upper genital tract disease among women presenting with signs and symptoms consistent with PID. Inconsistent condom use elevated the risk of upper genital tract inflammation.
"In [our] paper, we compared contraceptive methods in those women with endometritis with upper genital tract infection vs. those without either," observes Ness. "We found no contraceptive method to protect against true PID."
Look at OCs and PID
PID is a common condition in which microorganisms spread from the lower genital tract to infect and inflame the upper genital tract, including the endometrium, fallopian tubes, ovaries, and peritoneum. Women with PID have elevated rates of infertility, ectopic pregnancy, and chronic pelvic pain.
For more than a decade, there has been speculation on whether OCs offer some protection against PID caused by the ascent of chlamydial infection from the cervix into the fallopian tubes.5 OCs have been associated with a decreased risk of symptomatic PID.6
What are some possible reasons for this protective effect? According to Contraceptive Technology:
- The average amount of menstrual blood a woman loses each month is decreased. Menstrual blood may act as a cultural medium, facilitating PID’s development.
- Scanty and thick cervical mucus produced by OC use is difficult to penetrate, thereby discouraging the ascent of sperm into the vagina. Bacteria attached to the surface of sperm gain entry to the upper genital tract through the ascent of sperm.
- The cervical canal is less dilated, principally because the volume of cervical secretions and menstrual blood is diminished.
- Uterine contractions are decreased in strength, thereby decreasing the likelihood of spreading an infection from the uterine cavity into the fallopian tubes.7
Although some studies have shown that women are protected from gonorrhea and chlamydia by condoms,8 in recent prospective cohort studies, inconsistent condom use and even reports of consistent condom use have been less than optimal in preventing the acquisition of gonorrhea, chlamydia, and other bacterial STDs,9,10 observe Ness and co-authors.
In the current study, inconsistent use of condoms was associated with an increased risk of upper genital tract infection. Specifically, condom use in fewer than 100% of sexual encounters was associated with a more than twofold increase in risk.
However, consistent condom use was more protective than no contraceptive use, and inconsistent condom use increased risk, Ness points out. A major take-home point from the study is for providers to counsel patients not only on condom use, but their consistent and correct use as well, she states.
"Inconsistent [condom] use actually is a sign of increased risk, probably because patients who know that they are at risk feel that they should use condoms, but they don’t always use them," agrees Steven Sondheimer, MD, professor of obstetrics and gynecology at the University of Pennsylvania Medical Center in Philadelphia and a study co-author. "[Condoms are] protective only if they are used consistently and correctly."
References
1. Ness RB, Soper DE, Holley RL, et al. Hormonal and barrier contraception and risk of upper genital tract disease in the PID Evaluation and Clinical Health (PEACH) Study. Am J Obstet Gynecol 2001; 185:121-127.
2. Ness RB, Soper DE, Holley RL, et al. Douching and endometritis: Results from the PID Evaluation and Clinical Health (PEACH) Study. Sex Transm Dis 2001; 28:240-245.
3. Peipert JF, Ness RB, Soper DE, et al. Association of lower genital tract inflammation with objective evidence of endometritis. Infect Dis Obstet Gynecol 2000; 8:83-87.
4. Ness RB, Soper DE, Peipert J, et al. Design of the PID Evaluation and Clinical Health (PEACH) Study. Control Clin Trials 1998; 19:499-514.
5. Blackburn RD, Cunkelman JA, Zlidar VM. Oral Contraceptives — An Update. Population Reports. Series A, No. 9. Baltimore: Johns Hopkins University School of Public Health, Population Information Program; Spring 2000.
6. Wolner-Hanssen P, Eschenbach DA, Paavonen J, et al. Decreased risk of symptomatic chlamydial pelvic inflammatory disease associated with oral contraceptive use. JAMA 1990; 263:54-59.
7. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 17th revised ed. New York City: Ardent Media; 1998.
8. Cates W Jr. Contraception, contraceptive technology, and STDs. In: Holmes KK, Sparling PF, Mardh P-A, et al. Sexually Transmitted Diseases. New York City: McGraw Hill; 1999.
9. Weir SS, Feldblum PJ, Zekeng L, et al. The use of nonoxynol-9 for protection against cervical gonorrhea. Am J Pub Health 1994; 84:910-914.
10. Zenilman JM, Weisman CS, Rompalo AM, et al. Condom use to prevent incident STDs: The validity of self-reported condom use. Sex Transm Dis 1995; 22:15.
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