Actinomyces-like organisms in users of intrauterine contraception

Actinomyces-like organisms (ALO) were found in 6.9% of cervical smears in 2133 IUD users. The chance of having co-infection with Trichomonas vaginalis was 2.7 times higher in women with ALO than in ALO negative women. The proportion of IUD users with ALO in cervical smears increased with the duration of the IUD use. A total of 108 IUD users with ALO were compared with the same number of IUD users without ALO in cervical smears. The women in the two groups were matched for the duration of the IUD use. During the IUD use the women with ALO had PID and vaginitis significantly more frequently than ALO negative women. No difference was found regarding the type of the IUD used in women with ALO in cervical smears compared to controls.     

IUD induced bleeding and the way of therapy

In a retrospective study containing 2404 cases of IUD induced bleeding problems, the type and timing of bleeding as well as the types of conservative therapy were evaluated. The non-hormonal treatment (uterotonics, calcium, C- and K-vitamin etc.) proved to be significantly less effective (P < 0.05) than the hormonal therapy (estrogen, gestagen and combined preparations). The rate of effectiveness was 80.1% and 86.7%, respectively. Because the effectiveness of the conservative therapy is 80%, even in the non-hormonal group, the IUD should be removed only if this treatment proves to be ineffective. Attention is drawn to the importance of routine colposcopic and cytological screening.     

Cytologic picture of smears from the cervix uteri of women using intrauterine contraceptive devices (IUD)

During 1986-87, cervical smears were taken at various phases of menstrual cycles from 63 women aged 25-53 (average age of 34.8 years) wearing IUDs for 3 months to 17 years for the sake of cytological evaluation. 43 patients had Copper T-devices of Finnish make, 8 women had Spider Ws of Polish make, 1 had a Lippes Loop, and 10 had IUDs whose manufacturer could not be verified. The samples were preserved in an alcohol-ether solution, dyed with hematoxylin and eosin, and evaluated according to the 5-degree Papanicolaou scale. The presence of granulocytes indicative of inflammation was ranked: few granulocytes (+), the normal count in healthy women during anovulation wearing no IUDs; an adequate number of granulocytes (++); numerous granulocytes (+++); and a high number of granulocytes (++++). Cytogram II of the Papanicolaou scale was found in 49 women, and cytogram I in 14 women. 5 of 25 women wearing IUDs for 3 years had cytogram I, while 20 had cytogram II. Among 21 patients wearing IUDs for 2 years, there were 4 cases of cytogram I and 17 instances of cytogram II. Women with IUD use of 4-17 years were put into the second group, while all 4 of those with 3 months to 1.5 years of IUD use were listed in the first group. The remaining 6 were sorted into the second group. In 45 (71%) women, varying degrees of inflammation were detected in the presence of neutrophilic granulocytes. In 14 cases (22%) the presence of erythrocytes was demonstrated: few in 7 cases, an adequate number of 4, and an excess number in 3 cases caused either by the IUD or by hormone-induced cervical bleeding. Numerous neutrophilic granulocytes were found in 4 cases and a high number of them in 1 case. The granulocyte count was 10 (+), 17 or 16 (++), 12 (+++), and 6 (++++) indicating moderate or severe inflammation in most preparations. The presence of cytologically suspect or atypical cells was absent in the cervical smears of longterm IUD users. In most women, IUD use was associated with inflammation indicated by the increased number of granulocytes. The persistence of such inflammation may justify the removal of the IUD.     

Endo-cervical aspiration,vaginal cytology and bacterioscopic observation in CU-improved IUD carriers

After examining 146 copper-improved IUD users and comparing the vaginal bacterioscopic reports and the appearance of the cytological drawings obtained either traditionally or by endocervical aspiration with those from a test-group, the authors found nonappreciable differences, except for a more marked incidence of mycosis (11% against 7%) and 3 cases of slight dysplasia in the endocervical aspiration of IUD carriers, which were not statistically significant. The observations made for a slight cervical dysplasia were identical in both groups considered (3.5%). (Author's)     

Actinomyces israelii in the genital tract of women with and without intra-uterine contraceptive devices

Actinomycosis involving the female genital tract is more common among IUD users than others. The diagnosis is difficult and often delayed. It has been suggested that the finding of Actinomyces-like organisms or A. israelii in cervical smears indicates a risk of developing actinomycosis. A. israelii has not been regarded as a part of the indigenous genital flora. A group of IUD users without symptoms of genital tract infections were compared with a control group without IUDs. No Actinomyces-like organisms were found on cytological examination of cervical smears. Immunofluorescent staining and cultures identified A. israelii in 4% of the IUD users and in 3% of the non-users. Serologic precipitin tests for actinomycosis were negative in all women. None developed actinomycosis on follow-up of positive cases. The study indicates that A. israelii is a commensal of the female genital tract. The identification of A. israelii alone does not indicate that the patient risks developing actinomycosis. Other methods such as a serology test should be useful in defining the clinical significance of the findings.     

Cryosurgical treatment of cervical intraepithelial neoplasia (CIN III) in 102 patients

Results of cryosurgical treatment in 102 patients with a histologically confirmed diagnosis of severe dysplasia or carcinoma in situ of the uterine cervix (CIN III) are presented. The colposcopic evaluation performed in all patients required full visualization of the squamocolumnar junction. In 95 of the 102 patients no significant cytological abnormalities were found during the follow-up period, which amounts to a success rate of 93%. In seven patients (7%) treatment was considered to have failed because cervical smears persistently suggested CIN II or III. In five of them this was in all probability due to a residual lesion, since the abnormal smears occurred within 12 weeks after cryosurgery. It is concluded that in selected cases cryosurgery is a safe alternative for conisation in the treatment of CIN III. However, thorough colposcopic expertise is essential for adequate preoperative screening, as is careful selection of patients, and the latter may result in the withholding of cryosurgical therapy from 30% of patients with CIN III.     

异位妊娠与IUD关系的探讨(附107例分析)

本文根据我院1984～1990年间62,321妊娠妇女的资料分析,宫内妊娠与异位妊娠的发病率发生了高度显著的变化(P<0.01)。特别是带器异位妊娠与未带器异位妊娠、带器异位妊娠与带器宫内妊娠之间的比例,1990年与1984年相比,差别高度显著(P<0.01),说明带器异位妊娠发病率极显著地上升。进一步对107例带器异位妊娠进行分析,发现与环位异常有一定的关系,经B超测定环位异常者占53%(35/66);且大部分发生在带器1～4年期间(68%);输卵管病理未能证实与炎症有关。指出带器异位妊娠发病率逐年增高,应予重视,与IUD之间的关系仍需进一步探讨。     

Use of phase-contrast and interference-contrast microscopy for immediate cytological tests in gynaecological practice (author's transl)]

Vital cytological tests of cervical smears obtained from 1,083 patients in a gynaecological practice are reported. The smears had been taken in search for malignant changes, in addition to the need for appraisals of ovarian function and vaginal flora. Smears which produced suspicious colposcopic and vital cytological findings were restained by means of Papanicolaou stain. The diagnoses based on both methods were compared. The results have confirmed the vital cytological technique to be extremely suitable for functional and flora diagnosis, while the Papanicolaou method was found to be superior to vital cytology in cancer screening.     

Attitudes towards contraception and some reasons for discontinuation

3101 women aged 20-44 were surveyed in Flanders in 1982-83 concerning their perceptions of the contraceptive methods they used. The survey was part of a larger longitudinal study of changes in family formation in Belgium. Traditional and modern contraceptive methods were perceived very differently. Withdrawal/periodic abstinence and the condom were regarded as effective by 61% and 79% of respondents, while the IUD, pill, and female sterilization were believed by 99% of respondents to be effective. Traditional and intermediate contraceptive methods were believed to be less convenient to use, to be more frustrating sexually, but to be more natural. The IUD and pills were associated with higher risks of secondary effects, but oral contraceptive (OC) users believed their method to be much more harmful to their health than did IUD users. IUD users complained of physical secondary effects, while OC users complained of physical, psychic, and sexual secondary effects. Fewer IUD users than OC users believed their method to be highly effective. Considerable proportions of withdrawal, periodic abstinence, and condom users appeared to overestimate the efficacy of their method. Sterilization users believed the accessibility of their method to be significantly lower than did users of other methods, perhaps because sterilization has become accepted and widely available in Flanders only in the past few years. The most frequently cited advantages of withdrawal/periodic abstinence and the condom were naturalness, innocuity, and lack of secondary effects, while the most frequently cited advantage of OCs and sterilization was their efficacy. Ease of use and efficacy were both cited as advantages by IUD users. A large number of women, especially those using modern methods, stated their method had no major disadvantages. The principle disadvantages cited by withdrawal, abstinence, and condom users were low efficacy and inconvenience for sex life, while the principle disadvantages for the pill and IUD were health worries and secondary effects. Perception of the attributes of the contraceptive method used was influenced more by prior contraceptive use than by age, educational level, ideology or completeness of the family. As in other countries, users of modern methods seem to be more satisfied with their choice. Reasons for terminating use of different methods used in the past were directly related to their perceived disadvantages. Secondary effects and health worries were the major reasons for terminating OC and IUD use. A nonnegligible proportion who terminated IUD use cited its lack of efficacy.     

IUD and nulliparae (author's transl)

Contraception with the IUD is definitely on the increase in France where, in January 1978, there were about 850,000 users. According to the authors of this article the IUD is an excellent contraceptive method, except in the case of nulliparous women, who seem more susceptible to complications caused by IUDs. A survey of the published literature shows that uterine perforation is easier in nulliparous women, and that expulsion is more frequent, as is removal for reasons of bleeding and pain, and as unwanted pregnancy resulting from IUD failure. More importantly, frequency of infection is higher among nulliparous IUD wearers; it must be remembered that serious infection often leads to sterility. As a result of such findings nulliparity must be regarded as an absolute contraindication to the use of an IUD unless no other contraceptive choice is possible.     

Will progesterone save the IUD?

In 1971 we began studying pelvic inflammatory disease (PID) in IUD users by examining fallopian tube specimens obtained after elective female sterilization. We studied four groups: 175 nonhormonal-IUD users, 22 Progestasert users, 1,500 non-IUD users and 100 non-IUD users who had had IUDs in the past. We found histologically detectable salpingitis in 49% of the nonhormonal-IUD users, none of whom had symptoms of PID. Culture of 100 specimens from these nonhormonal-IUD specimens proved to be sterile. Viewing the inflammation as predisposing the tissues to bacterial infection would help explain the higher frequency of PID among IUD users than among nonusers. All the Progestasert users lacked histologically detectable salpingitis; the difference was statistically significant (p < 10(-6). This finding suggests that women using progesterone-releasing IUDs have a lower risk of developing PID than do users of other kinds of IUDs.     

Human chorionic gonadotrophin (hCG) in IUD users

The incidence of postimplantation pregnancy loss was assessed in 186 IUD users and 187 controls through use of a highly sensitive, specific radioimmunoassay for serum human chorionic gonadotropin (hCG). Previous studies have detected hCG in 10-19% of IUD users during the postovulatory phase of the menstrual cycle, indicating either that implantation had occurred or that the preimplantation blastocyst secretes detectable amounts of hCG. 3 of the 187 controls had detectable serum hCG and their serum luteinizing hormone (LH) concentrations exceeded 125 mIU/ml. In 3 of 186 IUD users, serum hCG was detected in the presence of normal or low serum LH concentrations. These findings suggest that the incidence of dectable hCG during the postovulatory phase is extremely low in IUD users and identical to that of postmenopausal and noncycling controls. It is concluded that embryonic implantation and subsequent early abortion are rare events in IUD users and that neither plays a role in the mode of action of the IUD.     

Abdominal wall actinomycosis associated with an IUD. A case report

Abdominal wall actinomycosis without pelvic organ involvement in users of intrauterine contraceptive devices (IUDs) has not been reported on previously. We encountered one such patient, whose uterine cervix was colonized superficially with Actinomyces. We suggest that systemic actinomycosis be included in the differential diagnosis of pain in IUD users when Actinomyces is found on Papanicolaou smears or in endocervical curettings. Such patients should be treated with appropriate antibiotic therapy, especially prior to any surgical intervention.     

Gardnerella vaginalis and mosaic colposcopic pattern of the cervix: casual or causal association?

We made a retrospective study of the flora found in the vaginal smears of sexually active women who presented with a mosaic colposcopic pattern of the uterine cervix in an attempt to study some of its epidemiologic factors. Of the 195 cervicovaginal cytologies of patients with mosaic, 61 revealed an abnormal flora (31.2%) while of the 9,856 patients without mosaic, only 2,234 cytologies had an abnormal flora (22.7%) demonstrating a statistically significant higher frequency (p less than 0.0001) of an abnormal flora in women with a mosaic pattern on the cervix. A statistically significant association (p less than 0.02) was encountered between the presence of Gardnerella vaginalis and the mosaic colposcopic pattern, and surprisingly a statistically greater frequency (p less than 0.05) of biopsied dysplasias in the same group. At the moment we can interpret these observations as nothing more than interesting initial findings.     

How to treat IUD complications

Contraindications to the use of an IUD are pregnancy, uterine malformation, nulliparity, and genital infection. IUD users must see a doctor regularly. Short-term complications are uterine perforations at time of insertion, a very rare occurrence in the hands of a skilled clinician. Long-term complications are pregnancy, ectopic pregnancy, and genital or pelvic infection, the most serious of all complications, and one which must be immediately treated, usually with antibiotics. Expulsion or translocation of the device are also possible; in this last case the IUD must be located and surgically removed. The most common side effect of IUD use is excessive bleeding, which can be successfully treated with ergot alkaloids.     

应用宫内节育器的妇女沙眼衣原体感染与子宫内膜中铜含量的关系

目的:探讨女性生殖道沙眼衣原体(CT)感染与宫内节育器(IUD)种类及内膜中铜含量的关系。方法:用聚合酶链反应检测65例置含铜IUD及97例置不锈钢单环的妇女宫颈分泌物CT;对因症取出IUD的20例妇女,取器后刮取子宫内膜,用原子吸收分光光度法测子宫内膜铜含量。结果:放置含铜IUD者CT感染率(3.1%)明显低于置不锈钢单环者(12.3%),P<0.05;放置含铜IUD的妇女子宫内膜铜含量明显高于置不锈钢单环者(P<0.05)。结论:含铜IUD对生殖道CT感染有抑制作用。含铜IUD可能通过释放的铜离子来发挥抗CT作用。     

Management of patients with two consecutive ASC-US smears

INTRODUCTION: To determine whether aggressive or expectative management of patients after two consecutive smears with atypical squamous cells of undetermined significance is preferable. To determine whether triage with high-risk human papillomavirus will identify all patients with cervical intraepithelial neoplasia grade 2 and 3. METHODS: 140 of 282 patients referred for colposcopy with two consecutive smears with atypical squamous cells of undetermined significance were only treated when abnormalities suggestive of high-grade cervical intraepithelial neoplasia were present at colposcopy. The other 142 patients underwent excision of all detected colposcopic abnormalities. Both groups were compared regarding the final cytological follow-up, the number of diathermy loop excisions, and the detection of cervical intraepithelial neoplasia. Retrospectively, the outcome of triage with high-risk human papillomavirus in the first group was investigated. RESULTS: There was no significant difference in final cytological follow-up between patients managed by expectative or by aggressive colposcopic management. Significantly less diathermy loop excisions (p < 0.001) are performed in case of expectative management. The sensitivity, specificity, negative- and positive predictive values of triage with high-risk human papillomavirus detection were comparable with those of colposcopy alone. CONCLUSIONS: Patients referred with two consecutive ASC-US smears may be followed with an expectative colposcopic management and cytological follow-up. Triage with high-risk human papillomavirus will reduce the number of referrals and colposcopies, but (cytological) follow-up remains necessary in all high-risk human papillomavirus negative patients as well.     

Vaginal and endocervical bacterial contamination in IUD users

The use of intrauterine devices is clearly related to a new aspect of infective pathology: bacterial contamination of the uterine cavity and its repercussions throughout the genital apparatus. Therefore the Authors decided to carry out a study of the vaginal and endocervical flora of 61 IUD users. This study has shown that pathogenic germs are present to a significant extent (82.3%) even when no clinical symptoms can be detected. The Group B streptococcus was detected in a high number of cases (10.6%) in the vaginal (9.8%) or endocervical tampon (11.5%).     

Ectopic pregnancy among past IUD users.

The relationship between return to fertility and pregnancy outcome in women with IUD removal for planned pregnancy as well as the frequency of ectopic pregnancy among all former IUD users in comparison with the general population was studied. The cumulative conception rate in the group of women with IUD removal for planned pregnancy (n = 748) was 93.7% after 5 years, 93.4% being intrauterine and 0.3% ectopic. Rates of ectopic pregnancy in women with IUD removed for planned pregnancy were 2.7/1000 women, 3.6/1000 deliveries and 2.9/1000 pregnancies vs. 3.9, 13.4 and 5.6 in the general population. Only when the number of deliveries is used as denominator, have these differences reached statistical significance (P less than 0.05). Except for bleeding/pain and PID removals (6.0 vs. 3.9), in all other groups of former IUD users the incidence of ectopic pregnancy was also lower than in the control group. From the results of this study it was concluded that former IUD users are not at an increased risk for ectopic pregnancy.