Risk factors for pelvic inflammatory disease in inner-city adolescents

Screening for asymptomatic chlamydia and gonorrhea in adolescent males in an urban pediatric emergency department

AIM

To determine the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) in young men seeking care in the emergency department (ED) for non-sexually transmitted infection (STI) related symptoms.

METHODS

This was a prospective, cross-sectional study in an urban ED. The main outcome was the rate of positive CT and GC on urine nucleic acid amplification testing in males aged 16-21 presenting with non-STI related complaints.

RESULTS

Two hundred and eighty-four patients were enrolled, 271 were included in the final data analysis [age range 16-21, median: 18 (quartiles 16-18, 19-21)]. Overall, 17 (6.3%, 95%CI: 4%-10%) tested positive for CT and 0% (95%CI: 0%-2%) were found to have GC. The proportion of sexually active subjects was 71% (95%CI: 65%-76%) and 2% (95%CI: 0.6%-4%) reported sex with men. Previous STI testing was reported in 46% (95%CI: 43%-54%) and 13% (95%CI: 8%-20%) of those patients previously tested had a history of STI. Of the patients who tested positive for CT in the ED, 88% (95%CI: 64%-98%) were successfully followed up.

CONCLUSION

The prevalence of CT infection found by screening was 6.3%. Screening and follow-up from the ED was successful. The findings justify routine STI screening in male adolescents presenting to the ED with non-STI related complaints.

Risk of psychiatric disorders following pelvic inflammatory disease: a nationwide population-based retrospective cohort study

Pelvic inflammatory disease (PID) a common infection in women that is associated with significant morbidity and is a major cause of infertility. A clear temporal causal relationship between PID and psychiatric disorders has not been well established. We used a nationwide population-based retrospective cohort study to explore the relationship between PID and the subsequent development of psychiatric disorders. We identified subjects who were newly diagnosed with PID between 1 January 2000 and 31 December 2002 in the Taiwan National Health Insurance Research Database. A comparison cohort was constructed for patients without PID. A total of 21 930 PID and 21 930 matched control patients were observed until diagnosed with psychiatric disorders, or until death, withdrawal from the NHI system, or until 31 December 2009. Adjusted hazard ratio (HR) of bipolar disorder, depressive disorder, anxiety disorder and sleep disorder in subjects with PID were significantly higher (HR: 2.671, 2.173, 2.006 and 2.251, respectively) than that of the controls during the follow-up. PID may increase the risk of subsequent newly diagnosed bipolar disorder, depressive disorder, anxiety disorder and sleep disorder, which will impair life quality. Our findings highlight that clinicians should pay particular attention to psychiatric comorbidities in PID patients.

Screening adolescents for sexually transmitted infections in the pediatric emergency department

OBJECTIVES

The objectives of this study were to determine the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infections among adolescents presenting to a pediatric emergency department (PED), to assess the association between these infections and certain risk factors, and to assess the feasibility of routine screening for sexually transmitted infections (STIs) in the PED.

METHODS

This was a prospective, observational cohort study. Three hundred seven adolescents aged 13 to 17 years in an urban PED in Bronx, NY, were enrolled in the study. Subjects provided urine samples for nucleic acid amplification testing for CT and GC and self-completed a confidential questionnaire to assess health care-seeking patterns, high-risk social behaviors, and the presence of abuse, depression, and suicidal ideation. Outcome measures include prevalence of STIs and association of STIs with responses to the confidential questionnaire.

RESULTS

Twenty subjects (6.5%) tested positive for an STI. Seventeen (5.5%) were positive for CT, 2 (0.7%) for GC, and 1 (0.3%) for both. Fourteen adolescents (70%) with a positive test were asymptomatic. Logistic regression yielded 4 factors significantly associated with an STI: female sex (odds ratio [OR], 4.02; 95% confidence interval [CI], 1.1-15.2), illicit drug use (OR, 3.3; 95% CI, 1.1-9.3), disclosure of sexual activity (OR, 9.3; 95% CI, 1.1-76.9), and report of a sexual encounter resulting in pregnancy (OR, 3.7; 95% CI, 1.3-10.4).

CONCLUSIONS

Sexually transmitted infections were common in asymptomatic adolescents presenting to the PED. We identified 4 risk factors that were significantly associated with STIs. Our findings may facilitate identification of adolescents at highest risk for STIs, help prevent further transmission of infection, and decrease morbidity in this marginalized population.

Testing and treatment for sexually transmitted infections in adolescents--what's new?

BACKGROUND

Significant changes are taking place in the diagnosis and management of sexually transmitted infections (STI) in adolescents and young adults.

FINDINGS

In this review article, we provide an update of STIs in adolescents and young adults including: (1) Adolescent risk; (2) Screening guidelines; (3) Clinical manifestations; (4) Diagnostic testing; (5) Treatment; and (6) Prevention; with an emphasis on "what's new" in the field.

CONCLUSIONS/SIGNIFICANCE

While the impacts of STI epidemiology and health care access are leading to new recommendations for screening and prevention, changes in technology and drug resistance are promoting new methods of STI testing and ongoing revisions of STI treatment recommendations.

A novel integration effort to reduce the risk for alcohol-exposed pregnancy among women attending urban STD clinics

Alcohol-exposed pregnancy (AEP) is a significant public health problem in the United States. Sexually transmitted disease (STD) clinics serve female clients with a high prevalence of heavy alcohol consumption coupled with ineffective contraceptive use. Project CHOICES (Changing High-Risk AlcOhol Use and Increasing Contraception Effectiveness) is an evidence-based, brief intervention to lower risk of AEP by targeting alcohol and contraceptive behaviors through motivational interviewing and individualized feedback. We describe our experience integrating and implementing CHOICES in STD clinics. This endeavor aligns with CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention's program collaboration and service integration strategic priority to strengthen collaborative work across disease areas and integrate services provided by related programs at the client level.

Correlates of self-reported pelvic inflammatory disease treatment in sexually experienced reproductive-aged women in the United States, 1995 and 2006-2010

BACKGROUND

Few studies have examined recent temporal trends in self-reported receipt of pelvic inflammatory disease (PID) treatment. We assessed trends in receipt of PID treatment and associated correlates using national survey data.

METHODS

We used data from the National Survey of Family Growth, a multistage national probability survey of 15- to 44-year-old women. We examined trends in self-reported receipt of PID treatment from 1995, 2002, to 2006-2010. In addition, we examined correlates of PID treatment in 1995 and 2006-2010 in bivariate and adjusted analyses.

RESULTS

From 1995 to 2002, receipt of PID treatment significantly declined from 8.6% to 5.7% (P < 0.0001); however, there was no difference from 2002 to 2006-2010 (5.0%, P = 0.16). In bivariate analyses, racial differences in PID treatment declined across time; in 2006-2010, there was no significant difference between racial/ethnic groups (P = 0.22). Also in bivariate analyses, similar to 1995, in 2006 to 2010, some of the highest reports of receipt of PID treatment were women who were 35 to 44 years old (5.6%), had an income less than 150% of poverty level (7.5%), had less than high school education (6.7%), douched (7.7%), had intercourse before age 15 years (10.3%), and had 10 or more lifetime partners (8.0%). In adjusted analyses, differing from 1995, women at less than 150% of the poverty level were more likely (adjusted odds ratio [AOR], 2.60; 95% confidence interval [CI], 1.79-3.76) than women at 300% or more of the poverty level to have received PID treatment in 2006-2010.

CONCLUSIONS

Receipt of PID treatment declined from 1995 to 2006-2010, with the burden affecting women of lower socioeconomic status.

Trends in illness severity and length of stay in inner-city adolescents hospitalized for pelvic inflammatory disease

BACKGROUND

In 1998, the Centers for Disease Control and Prevention (CDC) changed their guidelines for treatment of adolescents with pelvic inflammatory disease (PID), no longer recommending hospitalization of all teenagers.

STUDY OBJECTIVES

(1) To determine the proportion of adolescents with PID who were admitted for failed outpatient treatment after the CDC guideline change. (2) To determine if adolescents admitted for PID after the guideline change needed longer hospital stays and/or were more likely to be "very ill" [as measured by inflammation markers, e.g. fever] or to have tubo-ovarian abscess (TOA) than those admitted before the change.

DESIGN

Retrospective chart review

SETTING/PARTICIPANTS

All 12-21-year-old females with the diagnosis of PID admitted to an adolescent inpatient unit in an inner-city teaching hospital during a two-year period before [T1=1995-1997 (54 cases)] and after [T2=1998-2000 (91 cases)] the CDC guideline change.

INTERVENTIONS

None

MAIN OUTCOME MEASURES

Reason for admission (failed outpatient treatment; TOA; or admission at the time of diagnosis of PID); clinical toxicity at admission, and length of hospital stay (LOS).

RESULTS

During T2, 22% of PID admissions were for failure of outpatient therapy. However, those admitted after failure of outpatient therapy (n=20) in T2 were less likely to be "very ill" than those who were admitted at the time of PID diagnosis in either T1 or T2 (n=123) [RR:0.30; 95% CI:0.09-0.94]. Mean LOS for females admitted to the adolescent unit with all diagnoses other than PID did not change between T1 and T2 but mean LOS for those diagnosed with PID decreased significantly from 6.3 +/- 3.7 days to 4.7 +/- 2.7 days, respectively (P = 0.002). LOS for PID was longer for younger (<16 years; 8.20 +/- 4.5 days) than older (> or =16 years; 5.0 +/- 2.8 days) girls (P = 0.02) and for adolescents with TOA (7.9 +/- 5.0 days) than for those without (5.3 +/- 2.9 days) (P = 0.05).

CONCLUSION

At our medical center, after the CDC guideline change many adolescents with PID were admitted because of failure of outpatient therapy but they were not sicker than those admitted at the time of diagnosis and overall LOS for PID was shorter. These findings are reassuring because they suggest that an initial trial of outpatient therapy for PID is unlikely to harm adolescents and may lead to significant cost savings.

Benign gynecologic conditions

Benign gynecologic conditions constitute the majority of the general gynecologist's practice. Along with health maintenance examinations, contraceptive management, family planning issues, and concerns about incontinence, the gynecologic conditions for which patients commonly present include adnexal masses, leiomyomata, endometriosis, and pelvic inflammatory disease. This article addresses each of these last four entities and incorporates a discussion of their etiologies, clinical presentations, keys to diagnosis, and the various treatment options available.

Pelvic inflammatory disease in adolescents

PURPOSE OF REVIEW

We discuss the epidemiology, risk factors, microbiology, diagnosis, treatment and prevention of pelvic inflammatory disease in adolescents.

RECENT FINDINGS

Young age is one of the most important risk factors for sexually transmitted diseases and pelvic inflammatory disease. Sexually active adolescents have the highest incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, and pelvic inflammatory disease of any sexually active age group. Long-term sequelae of pelvic inflammatory disease include ectopic pregnancy, tubal factor infertility, tubo-ovarian abscesses and chronic pelvic pain. Subclinical pelvic inflammatory disease is responsible for a significant portion of these long-term sequelae. New (2006) Centers for Disease Control and Prevention treatment guidelines for pelvic inflammatory disease are available. One of the best methods of prevention of pelvic inflammatory disease is to screen and treat sexually active adolescents for chlamydial infection. Implementation of nucleic acid amplification assays allows screening of adolescents via self-collected urine or vaginal swab samples.

SUMMARY

Pelvic inflammatory disease is a highly preventable source of reproductive morbidity for adolescents. It is prudent that clinicians provide counseling regarding healthy sexual behaviors, STD prevention, and contraception whenever an adolescent presents in need of STD screening or evaluation for pelvic inflammatory disease.

First sexual partnerships--age differences and their significance: empirical evidence from the 2000 British National Survey of Sexual Attitudes and Lifestyles ('Natsal 2000')

PURPOSE

To describe variations in age differences (ADs) between partners at first heterosexual intercourse and to examine associations between this AD, sociodemographic characteristics, and circumstances of first heterosexual intercourse, by gender.

METHODS

A total of 3277 men and 4734 women aged 25-44 years who reported ever having heterosexual intercourse in a probability survey of the British population to obtain an unbiased sample of ADs at first intercourse. Face-to-face interviews collected sociodemographic data and information on first intercourse. Gender-specific cumulative distributions of ADs categorized respondents reporting relatively younger first partners (below fifth percentile) and those reporting relatively older first partners (above 95th percentile).

RESULTS

Relatively older first partners were six years older than men and 10 years older than women. Relatively younger first partners were three years younger than men and one year younger than women. Men and women with relatively older first partners were more likely to have just met their partner (odds ratios adjusted for sociodemographic characteristics [AOR] 1.8, 95% confidence interval [CI] 1.2-2.7, and 3.1, 95% CI 2.1-4.6, respectively); had a more willing first partner (AOR 2.1, 95% CI 1.2-3.8, and 1.6, 95% CI 1.2-2.2, respectively); not used condoms at first sex (AOR 1.9, 95% CI 1.2-3.0, and 1.5, 95% CI 1.1-2.0, respectively); and reported a non-autonomous reason for first sex (AOR 1.6, 95% CI 1.1-2.4, women only). Men with relatively younger first partners were more likely to regret the timing of the first occasion (AOR 2.1, 95% CI 1.0-4.5).

CONCLUSIONS

First partnerships involving relatively older or younger partners are associated with adverse circumstances of first intercourse. Condoms and other reliable contraception are less likely to be used, and age differences may reflect unequal power relations. Promoting effective communication and negotiation skills may be particularly important for those with relatively older or younger first partners.

Prediction of pelvic inflammatory disease among young, single, sexually active women

OBJECTIVES

To assess prediction strategies for pelvic inflammatory disease (PID).

STUDY DESIGN

One thousand one hundred seventy women were enrolled based on a high chlamydial risk score. Incident PID over a median of 3 years was diagnosed by either histologic endometritis or Centers for Disease Control and Prevention criteria. A multivariable prediction model for PID was assessed.

RESULTS

Women enrolled using the risk score were young, single, sexually active, and often had prior sexually transmitted infections. Incident PID was common (8.6%). From 24 potential predictors, significant factors included age at first sex, gonococcal/chlamydial cervicitis, history of PID, family income, smoking, medroxyprogesterone acetate use, and sex with menses. The model correctly predicted 74% of incident PID; in validation models, correct prediction was only 69%.

CONCLUSIONS

Our data validate a modified chlamydial risk factor scoring system for prediction of PID. Additional multivariable modeling contributed little to prediction. Women identified by a threshold value on the chlamydial risk score should undergo intensive education and screening.

Pelvic inflammatory disease in adolescents: high incidence and recurrence rates in an urban teen clinic

STUDY OBJECTIVE

To determine pelvic inflammatory disease (PID) incidence and recurrence rates in an urban teen clinic.

DESIGN/SETTING

A retrospective chart review of female patients seen as outpatients over an 18-month period at an urban teen clinic. 192 patients were diagnosed with PID, and the charts of these patients were reviewed in depth.

MAIN OUTCOME MEASURES

PID incidence and recurrence rates.

RESULTS

A PID incidence of 9.7% was identified. Of the adolescent females diagnosed with PID, 47% had recurrent PID. Of the females with recurrent PID, 27% had three or more episodes. Only 36% of adolescent females diagnosed with PID ever reported that their partners had been treated.

CONCLUSIONS

This study suggests a higher incidence of PID as well as PID recurrence in the present clinic-based adolescent population than previously reported. More accurate monitoring of incidence and recurrence rates in well-defined populations of adolescents should be conducted with the hope of identifying effective avenues of intervention.

Self-Reported Symptoms of Reproductive Tract Infections Among Rural Women in Hainan, China: Prevalence Rates and Risk Factors

OBJECTIVES AND GOAL

The goal of this study was to examine risk of reproductive tract infections (RTIs) among women in rural China, including prevalence, influence of sociodemographic characteristics, knowledge, hygienic practices, attitudes, and behaviors related to premarital and extramarital sex, and abortion.

STUDY

During 2000, a stratified cluster sample of 606 rural married women in Hainan province completed an interviewer-administered standardized questionnaire.

RESULTS

Overall, 39% of participants reported at least 1 RTI symptom in their lifetime and 20% during the past 6 months. Having had premarital sex, having sex during menstruation, belonging to an ethnic minority, being knowledgeable about RTIs, and living in a village at medium economic level were all related to having RTI symptoms.

CONCLUSION

Among married women in rural China, the prevalence of RTI symptoms was high, indicating the need for health education, particularly targeting women from ethnic minorities and resource-poor areas.

Epidemiology of female genital Chlamydia trachomatis infections

The World Health Organization (WHO) has estimated that 92 million new cases of C. trachomatis (Chlamydia trachomatis) infection occur each year. This chapter focuses on the epidemiology of C. trachomatis infection, including the prevalence of infection in high- and low-risk groups, the incidence of infection, and data on secular trends. The evidence on the transmission of infection is reviewed. Risk factors for C. trachomatis infection in women are discussed. The adverse sequelae associated with C. trachomatis infection are described. Areas requiring further research are highlighted.