IUD Not Recommended for Increased STD Risk

Recent research, however, suggests some at risk of infection may be appropriate users.

Network: 2000, Vol. 20, No. 1

Intrauterine devices (IUDs) are contraindicated or considered undesirable for women at risk of sexually transmitted diseases (STDs), including HIV, or for women infected with STDs.

Concerns focus on health risks to the woman, as well as to her sexual partner. Yet, for some of these women and their partners, IUDs may be effective, safe and desirable as long as the women have access to appropriate medical tests or services.

Like other nonbarrier contraceptive methods, IUDs do not protect men or women from any STD. HIV-positive women and men should always be encouraged to advise their partners of their HIV status and to use condoms consistently.

The World Health Organization's (WHO) medical eligibility criteria for safe use of contraceptives state that insertion of a Copper T IUD in an HIV-infected woman or one who is at high risk of infection is not usually recommended.¹ Safety concerns for HIV-positive women using IUDs include the fear that a woman's immune system may be weakened and unable to fight off infections, such as other STDs that could lead to pelvic inflammatory disease (PID). This inflammation of a woman's upper genital tract -- quite often caused by the bacteria Neisseria gonorrhoeae or Chlamydia trachomatis -- can lead to chronic pelvic pain, infertility, ectopic pregnancy and sometimes even death.

However, recent research conducted in Kenya by investigators at the University of Nairobi and FHI found that 156 HIV-infected women -- including those whose immune systems were suppressed at the time of IUD insertion -- had no more overall complications at one, four and 24 months following insertion than did 493 uninfected women.² Overall complications were defined as PID; removal due to infection, bleeding or pain; and expulsion or pregnancy.

"There was weak evidence of more infection-related complications -- defined as PID, pelvic tenderness, and removal due to infection or pain -- with IUD use longer than five months," says Dr. Charles Morrison, an FHI epidemiologist who designed the research. "Nevertheless, PID was rare among both HIV-infected and uninfected IUD users. These findings suggest that the IUD may be a safe contraceptive method for appropriately selected HIV-infected women with continuing access to medical services. It also suggests that IUDs should continue to be offered in areas with high prevalence of HIV."

WHO guidelines were published in 1996, before the Kenyan study was conducted. However, until further research clarifies the issue, WHO is not expected to change its guidelines stating that use of a copper IUD is not usually recommended for HIV-infected women, says Dr. Patrick Rowe, medical officer of WHO's Department of Reproductive Health and Research.

Safety concerns for the sexual partners of HIV-infected IUD users arise from the fact that IUDs can cause an increase in menstrual bleeding (heavier or irregular bleeding). Greater exposure to infected blood theoretically could increase a partner's risk of infection. In theory, IUDs may also increase cervical shedding of HIV-infected cells, which may increase a partner's exposure.

However, in the Kenya study of HIV-infected women, no increase in cervical shedding of HIV occurred four months after IUD insertion, compared to before IUD insertion.³ And IUD use did not increase HIV transmission to the male partner in the only study to consider the effect of IUD use on female-to-male HIV transmission. In a study among 563 couples, only one of 10 men whose regular partner was an HIV-infected IUD user became infected. This infection rate was similar to that of 86 men whose partners were HIV-infected women not using IUDs or other contraception.⁴ "The data from these studies suggest that IUD use by HIV-infected women does not appear to make them more infectious to their sexual partners," says Dr. Morrison.

Studies of some 1,400 women seen at family planning clinics in Tanzania and some 800 sex workers seen at an STD clinic in Kenya suggest that IUD use does not increase a healthy woman's risk of acquiring HIV from an infected sexual partner,⁵ although some study results are conflicting.

Other STDs

Any woman with a cervical infection -- particularly gonorrhea or chlamydia -- is at greater risk of PID than an uninfected woman, whether or not she is using an IUD. Women at high risk for cervical infections include those living in areas with a high prevalence of the diseases, and those who engage in high-risk sexual behaviors, such as having multiple sexual partners or having sex with a man who has multiple partners.

"Among women who have an IUD inserted, women with cervical infections appear more likely to develop PID than are women who do not have a cervical infection," Dr. Morrison says. What accounts for this small increase in PID risk? It is thought that the process of IUD insertion can introduce STD-causing bacteria from the cervix into the uterus and fallopian tubes, which can later cause PID. WHO studies involving nearly 23,000 IUD insertions demonstrated that IUD users rarely develop PID after the first 20 days following insertion. The rate of PID immediately after insertion was 9.7 per 1,000 woman-years. Thereafter, for up to eight years later, PID risk among IUD users was 1.4 per 1,000 woman-years.⁶ PID risk among non-IUD users varies, largely depending upon the STD prevalence in an area.

Recent studies have shown that about 95 percent of women with cervical infections did not develop PID in the months following IUD insertion. Yet, identifying women with cervical infections or those who are at increased risk is desirable, since the PID risk is higher for these women.

Women who are identified with cervical infections usually are denied IUD use. WHO's medical eligibility criteria for safe use of contraceptives state that current infection with an STD contraindicates IUD use, as does any previous STD infection that has not been cured for at least three months. An IUD usually is considered undesirable for a woman at increased risk of STDs.⁷

Current research, however, indicates IUD use may be unnecessarily restricted for some women, says Dr. David Grimes, FHI vice president of biomedical affairs. For example, after the insertion period, most pelvic inflammatory disease in IUD users is thought to be acquired from men with STDs. "While international guidelines recommend that women who choose any other contraceptive method -- pills, injectables, implants, sterilization -- use male latex condoms for STD protection, guidelines do not suggest such dual method use for IUD users," he says. "Guidelines simply prohibit use of IUDs and recommend women choose another contraceptive." Dr. Grimes suggests that recommending dual method use may be appropriate for some IUD users.

While some providers are becoming aware that new research raises questions about the guidelines, they continue to follow them to be prudent. "What we teach students about IUDs and currently practice in Kenya is based upon WHO recommendations," says Dr. Boaz Otieno-Nyunya of Moi University, Eldoret, Kenya, and a former FHI fellow. "We are being conservative."

Screening

Identifying women with cervical infections can be difficult. When available, laboratory tests to identify STDs associated with the development of PID can rule out infection, making IUD insertion safe as long as a woman abstains from sexual relations or uses a condom correctly and consistently between the time of the test and IUD insertion. But current lab tests require an additional clinic visit -- prior to the IUD insertion visit -- which entails time, money and inconvenience for clients. Requiring such tests can discourage some women from obtaining an IUD. Also, many clinics in developing countries cannot afford laboratory tests for women requesting IUDs.

The WHO guidelines discouraging IUD use in women at STD risk were designed with this in mind, says Dr. Rowe of WHO. "They are aimed primarily at IUD providers in developing countries where there are no laboratory facilities for ruling out current lower genital tract infection," he says.

Providers lacking laboratory facilities can predict the likelihood of STD infection by screening women requesting IUDs, such as asking about a client's personal history. But this is a less precise way of ruling out STD infection.

In a Brazilian study in which 327 women were deemed eligible for an IUD after rigorous STD screening based on their sexual history and a clinical exam, 19 (6 percent) were found after IUD insertion to have a positive chlamydia laboratory test result, and one woman was diagnosed with PID within two weeks of insertion.⁸ Screening included questions about the socioeconomic characteristics and sexual behavior of women and their partners, and evaluation of patients' gynecological symptoms and signs.

The study's authors noted that the PID rate was low. Still, screening procedures "were not as effective as previously assumed in preventing insertion of the IUD among women with endocervical infection," they concluded.

Yet, rigorous STD screening for IUD candidates, based on personal history and clinical exams, should be maintained, says Dr. Soledad Díaz, director of the Instituto Chileno de Medicina Reproductiva in Santiago, Chile. Dr. Díaz, a member of the International Medical Advisory Panel of the International Planned Parenthood Federation (IPPF), was one of the experts who developed the WHO medical eligibility criteria. Such screening is used successfully in Chile, where some 70 percent of women receiving public-sector family planning services use the IUD. "As a result of rigorous screening and treatment before IUD insertion of all women with signs of infection, only one of some 5,000 patients receiving an IUD in our clinic developed severe PID, and that occurred more than one year after the insertion," says Dr. Díaz.

"Rigorous screening of women to identify those likely to have an STD at the time of IUD insertion is especially important in developing countries," she says. "If PID due to an undetected STD occurs after an IUD is inserted, the PID can nearly always be treated with antibiotics; however, many women in developing countries lack access to medical services and treatment."

U.S. Agency for International Development guidelines recommend using personal history and sociodemographic factors (such as marital status) to predict the likelihood that an IUD candidate has an STD. A physical exam of the reproductive organs may also detect some STDs. In some settings, the guidelines state, it may be appropriate to supplement such screening with laboratory tests.⁹

In the Republic of Karakalpakstan (Uzbekistan), where the majority of contracepting women use IUDs, laboratory testing for syphilis, gonorrhea and trichomoniasis is readily available through the public health system, despite limited resources. "In addition, we have found it helpful to provide screening and a clinical exam for women requesting IUDs," says Dr. Oral Ataniyazova of the Karakalpak Center for Reproductive Health and Environment.

However, criteria for identifying a woman's risk for STD are not clearly stated in most family planning programs worldwide. Researchers from AVSC International, in collaboration with the Instituto Mexicano del Seguro Social (IMSS), recently found that the IMSS had no established STD risk assessment protocol. The finding was part of a larger assessment of the capacity of Mexican service delivery systems to provide IUDs safely.¹⁰

Researchers also found that providers' clinical assessments of women requesting IUDs were often incomplete. Providers conscientiously reviewed medical histories and performed speculum exams, but did not consistently perform manual exams. Speculum exams help providers observe the cervix and any discharge associated with infection. Manual exams can enable providers to identify abdominal tenderness caused by infection or more serious conditions.

Similar studies were conducted by AVSC International in Kenya, Ghana and Russia. Researchers found that manual exams of the reproductive organs were not consistently performed, except in Ghana and one site in Kenya, says Dr. Mark Barone, AVSC International medical associate and a principal researcher for the studies. In all four countries, providers were inconsistent in the questions they asked clients to assess their risks of STDs.

Population Council researchers have measured the effect on contraceptive method choice of giving Mexican women information about contraceptives (including IUDs), their benefits and risks, and information about STDs and PID. Half of the 2,107 women in the study, which was conducted in a family planning clinic, were assigned to a group that received this information and half were assigned to a standard care group. Laboratory tests identified 2 percent of women as having chlamydia or gonorrhea, although this information was not shared with the women or their doctors until after they had indicated a preferred method for themselves or their patients.

No infected woman actually received an IUD. But, despite being trained to recognize the signs and symptoms of STDs, the doctors recommended the use of IUDs to 95 percent of 21 infected women in the standard care group. In contrast, only half of 23 infected women in the informed group chose the IUD as an appropriate contraceptive for themselves.

"This indicates that doctors can be trained about STDs and still not be able to identify cervical infection" without the help of laboratory tests, says Dr. Beverly Winikoff, program director of reproductive health at the Population Council. "In addition, it may be difficult for physicians to discuss STD risk with their patients. Sexual behavior is a sensitive subject. A woman may know something that puts her at risk, but not be able to recognize fully or admit the danger to a health professional."

Some developing countries use algorithms -- a list of simple questions about a client's behavior and social circumstances -- to assess risk of infections. Even providers with little training can use the algorithms to help decide whether women are eligible for IUDs when laboratory tests are not available. However, the algorithms tend to be imprecise. Researchers from the University of Nairobi and FHI have developed an STD risk assessment algorithm to predict cervical infection among IUD candidates seen at family planning clinics. Preliminary findings are promising, but the new algorithm must be evaluated further.¹¹

-- Kim Best

References

1. World Health Organization. Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. (Geneva: World Health Organization, 1996)132.
2. Sinei SK, Morrison CS, Sekadde-Kigondu C, et al. Complications of use of intrauterine devices among HIV-1 infected women. Lancet 1998;351(9111):1238-41; Morrison C, Sekadde-Kigondu C, Sinei S, et al. Is the IUD appropriate contraception for HIV-infected women? Presentation at Thirteenth Meeting of the International Society for Sexually Transmitted Diseases Research, Denver, CO, USA, July 11-14, 1999.
3. Richardson BA, Morrison CS, Sekadde-Kigondu C, et al. Effect of intrauterine device use on cervical shedding of HIV-1 DNA. AIDS 1999;13(15):2091-97.
4. European Study Group on Heterosexual Transmission of HIV. Comparison of female to male and male to female transmission of HIV in 563 stable couples. BMJ 1992;304(6830):809-13.
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6. Farley TM, Rosenberg MJ, Rowe PJ, et al. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1992;339(8796):785-88.
7. World Health Organization, 132.
8. Faúndes A, Telles E, Cristofoletti ML, et al. The risk of inadvertent intrauterine device insertion in women carriers of endocervical Chlamydia trachomatis. Contraception 1998;58(2):105-9.
9. U.S. Agency for International Development. Recommendations for Updating Selected Practices in Contraceptive Use: Volume I. (Washington: U.S. Agency for International Development, 1994)90.
10. Factors Affecting the Safe Provision of IUDs: A Service Delivery Perspective from Mexico. New York: AVSC International and Instituto Mexicano del Seguro Social (IMSS), 1999.
11. Morrison CS, Sekadde-Kigondu C, Miller WC, et al. Use of sexually transmitted disease risk assessment algorithms for selection of intrauterine device candidates. Contraception 1999;59(2):97-106.

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