Serious pelvic infections associated with intrauterine contraceptive device

A study undertaken to discover whether the incidence and types of intrauterine bacterial growth in IUD users differed from those in nonusers is described. The study 1)compared the early development of infection in IUD users and nonusers, and 2) looked for a correlation between known serious pelvic infection and IUD use. Of 235 patients seen for gynecologic examination (131 IUD users and 104 nonusers), 21 users for 6 months or more and 1 user for less than 4 months had foul-smelling leukorrhea, irregular bleeding, or both. Endometrial cultures were positive in 67% of users, and in 62% of the nonusers. 11 long-term IUD users more than 6 months and 1 nonuser had anaerobic organisms (p less than .01). Of 31 patients admitted for tubo-ovarian or pelvic abcesses, 17 were IUD users, of whom 9 required hysterectomy. Earlier recognition of foul-smelling mucoid discharge on the IUD tail, or abnormal bleeding, or both, as a sign of early pelvic infection, followed by removal of the IUD and institution of appropriate antibiotic therapy, might prevent the more serious sequelae of pelvic inflammation.     

Relationships between contraception and gynecologic infections

Infections of the upper genital tract are commonly referred to as pelvic inflammatory disease (PID) and are often accompanied by fever, leucocytosis, and adnexal tumefaction. Risk factors are sexual activity at an early age, types of microbes, number of partners, and frequent sexual intercourse. Some studies found more incidence of mycotic vaginitis in women using oral contraceptives (OC) with a high estrogen content. It was also suggested that OC use reduced gonococcal pelvic infections by 50% by means of reducing menstrual flow and by modifying cervical mucus, making it impenetrable to bacteria. Nevertheless, OCs protect only in severe cases of PID. OC users appear to have a higher rate of chlamydial infections of the lower genital tract. IUD users have a 1.6 to 9.3 times higher risk of getting pelvic infections depending on age, number of partners, and frequency of intercourse. The risk is highest in the first 30 days after receiving the IUD, and long use (2 years) augments the risk of severe PID. There is increased risk of gonococcal infection in IUD users. Significantly increased numbers of anaerobic bacteria are present in cervical cultures of IUD users. Longterm IUD use is linked to a higher prevalence of actinomycetes. Among barrier methods, the use of the condom reduces the risk of infection with gonorrhea or chlamydia eightfold. The diaphragm provides effective protection against gonococcal and chlamydial infections, although its incorrect size and prolonged contact with spermicide can produce microlesions. Sterilization is associated with the reduction of genital infections; however, these are low-risk women aged 30 who are married. The spread of sexually transmitted diseases is an important factor to consider when choosing a contraceptive.     

Pathogenesis of acute pelvic inflammatory disease: role of contraception and other risk factors.

In a case-control study of matched pairs, the risk of acute pelvic inflammatory disease (PID) was 4.4 times higher in intrauterine contraceptive device (IUD) users than in nonusers (p less than 0.001). Of approximately 500,000 cases of acute PID occurring annually in the United States, an estimated 110,000 are attributable to IUD's, costing over forty-four million dollars per year. PID was attributable to the IUD in 77 per cent of IUD users. No particular type of IUD was implicated. The relative risk of acute PID in IUD users over nonusers was higher in nulligravid women than in previously pregnant women and was directly related to socioeconomic status (SES), but the total annual risk of PID in IUD users appear inversely related to SES. IUD use significantly increased the risk of nongonococcal PID. Fever occurred in 13 (21 per cent) of 61 IUD users and 59 (41 per cent) of 143 nonusers (p less than 0.025). Among women with nongonococcal PID, and adnexal mass greater than or equal to 6 cm. was noted in 14 (40 per cent) of 35 IUD users and in only 12 (15 per cent) of 78 nonusers (p less than 0.01). An increased risk of gonococcal PID was found among non-Caucasians and women not using contraception, while the risk of nongonococcal PID was increased among women with a past history of gonorrhea. Oral contraceptive use may protect women with gonorrhea from developing PID. Menstruation precipitates the onset of symptoms of gonococcal PID.     

Contraception and pelvic infection in women

Although sexually transmitted diseases are a major public health problem at the international level, the relationship between contraception and pelvic infection is seldom examined. Numerous STDs are more difficult to diagnose, more frequent, and more serious in women than in men. Differential diagnosis between pelvic infection and other intraabdominal syndromes has been a concern for practitioners for years, and many pelvic infections are probably never diagnosed. Lower abdominal pain and sensitivity as well as fever, leucocytosis, accelerated sedimentation rate, inflammatory annexial mass evident on sonography, and microorganisms in the pouch of Douglass and presence of leucocytes in the peritoneal fluid are diagnostic criteria. Apart from errors in treatment resulting from errors in diagnosis, pelvic infections are often inadequately treated, especially in the initial phase before symptoms are confirmed. The exact incidence of pelvic infections in the US is unknown, but pelvic inflammatory disease (PID) accounted for over 200,000 hospitalizations per year between 1970-75. PID carries grave risks of subsequent ectopic pregnancy, chronic pelvic pain, and infertility which is more likely as the number of acute episodes increases. The female genital tract has diverse microenvironments propitious for growth of microorganisms of different types, aerobic and anaerobic. Each anatomic site has specific features conditioning bacterial growth. Histological modifications during the menstrual cycle and pregnancy affect the microbial flora. Except in the case of gonorrhea, it is not known how many female lower genital tract infections spread to the upper tract. Since 1970, several studies have domonstrated a growing diversity of cervical and vaginal flora in asymptomatic subjects. The principal risk factors for PID have been well described in the literature. All contraceptive methods except the IUD provide some degree of protection against PID. Even among IUD users the risk of PID is probably not greater than among women with a comparable risk of exposure to STDs. The protective effect of condoms has been recognized since the era of Casanova, but it is difficult to quantify. Studies describing the protective effects of spermicides used one against pelvic infection are very rare, and protective effects have usually been demonstrated only in vitro. Surfactants such as nonoxynol probably have viricidal properties against herpes simplex. Condoms and diaphragms have been seen to exercise a protective effect independent of spermicide, with relative risks of .6 and .4 compared to nonouse of contraception. There is as yet no consensus on changes in risk of PID during oral contraceptive (OC) use, but several studies have shown OCs to have a protective effect. Risks of PID in IUD users apparently stem from contamination during insertion or of the thread during prolonged use, but both possibilities remain controversial. The use of women not using contraception as controls in studies of relative risks of PId may not be appropriate because their sexual behavior and risks of exposure to STDs may differ. At the moment of ovulation, when the mucus is most receptive, IUDs do not place any barrier in the way of ascension of sperm and bacteria to the upper genital tract.     

Extent of surgery for pelvic inflammatory disease in relation to duration of intrauterine device use

The risk of a first episode of pelvic inflammatory disease resulting in extensive surgery was examined in relation to duration of intrauterine device (IUD) use in a case-control study. Extensive surgery for pelvic inflammatory disease was defined as hysterectomy or bilateral adenexal surgery, with pelvic inflammatory disease as the only gynecologic discharge diagnosis. Of 690 hospitalized pelvic inflammatory disease patients with no prior history of the disease, 55 had extensive (requiring surgery) disease. These were compared to 2569 controls who were hospitalized with nongynecologic conditions. Current IUD users (within 30 days of admission) were considered to be long-term or short-term users, depending upon whether the same IUD had been used for five or more years or less than five years. Past IUD users and never-users were considered to be nonusers. For long-term users as compared to nonusers, the relative risk of extensive pelvic inflammatory disease was about 5.4; for short-term users as compared to nonusers, the relative risk was only about 1.4. Continuous use of the same IUD for five or more years appears to increase the risk of pelvic inflammatory disease, requiring extensive surgery to a greater extent than use for less than five years.     

Fertility after contraception or abortion

There is a very small correlation, if any, between the prior use of OCs and congenital malformations, including Down's syndrome. There are few, if any, recent reports on masculinization of a female fetus born to a mother who took an OC containing 1 mg of a progestogen during early pregnancy. However, patients suspected of being pregnant and who are desirous of continuing that pregnancy should not continue to take OCs, nor should progestogen withdrawal pregnancy tests be used. Concern still exists regarding the occurrence of congenital abnormalities in babies born to such women. The incidence of postoperative infection after first trimester therapeutic abortion in this country is low. However, increasing numbers of women are undergoing repeated pregnancy terminations, and their risk for subsequent pelvic infections may be multiplied with each succeeding abortion. The incidence of prematurity due to cervical incompetence or surgical infertility after first trimester pregnancy terminations is not increased significantly. Asherman's syndrome may occur after septic therapeutic abortion. The pregnancy rate after treatment of this syndrome is low. The return of menses and the achievement of a pregnancy may be slightly delayed after OCs are discontinued, but the fertility rate is within the normal range by 1 year. The incidence of postpill amenorrhea of greater than 6 months' duration is probably less than 1%. The occurrence of the syndrome does not seem to be related to length of use or type of pill. Patients with prior normal menses as well as those with menstrual abnormalities before use of OCs may develop this syndrome. Patients with normal estrogen and gonadotropin levels usually respond with return of menses and ovulation when treated with clomiphene. The rate for achievement of pregnancy is much lower than that for patients with spontaneous return of menses. The criteria for defining PID or for categorizing its severity are diverse. The incidence of PID is higher among IUD users than among patients taking OCs or using a barrier method. The excess risk of PID among IUD users, with the exception of the first few months after insertion, is related to sexually transmitted diseases and not the IUD. Women with no risk factors for sexually transmitted diseases have little increased risk of PID or infertility associated with IUD use. There appears to be no increased risk of congenital anomalies, altered sex ratio, or early pregnancy loss among spermicide users. All present methods of contraception entail some risk to the patient. The risk of imparied future fertility with the use of any method appears to be low.(ABSTRACT TRUNCATED AT 400 WORDS)     

Earth, motherhood, and the intrauterine device.

Commentary is provided on the relationship between the use of the IUD and infertility from the development of pelvic inflammatory disease (PID), preventive behavior for those using an IUD, and recent reviews of the Dalkon Shield. Among IUD users who have never been pregnant, tubal infertility is increased 2-6 fold (200-600%), and most with tubal infertility will never bear a child. Tubal infertility develops in 11% of patients with PID, but most IUD users do not develop PID. The physicians responsibility is 1) to give formal and extensive recognition to the connection that IUD uses causes PID; 2) to inform patients of the potential risk of PID and sterility; 3) to develop proper patient selection for an IUD; 4) to identify and treat PID, which may appear initially as abnormal uterine bleeding and mild pain; 5) to recognize that the IUD facilitates the development of PID in patients with Neisseria gonorrhoea and Chlamydia trachomatis even though 25-50% of IUD patients have neither infection; 6) to recognize that the risk of PID is increased in the first 4-6 months of insertion and to research alternatives, e.g. the use of available antibiotics to treat selected patients to reduce infections, and 7) to realize that most PID occurs 6 months after insertion and indolent abscess formation is expected to increase among longterm copper IUD users. The reviews referred to in this article are ones claiming unfair removal of the Dalkon Shield in 1974 based on flawed study design and analysis of case control and the understanding that the Dalkon Shield is no worse than other IUDs and not related to PID. The author points out that neither review mentions that primary tubal infertility increased 6-fold among Dalkon Shield users who had used only 1 IUD in their life, and that infertility increased 3-fold among IUD users compared with the non-IUD using population. The case control studies provide enough evidence for the cause and effect relationship. The Kronmal et al. article did not present convincing new evidence even with reanalysis of the original Lee et al. data. In the Memford and Kessel review case controlled studies are excluded from consideration. Most PID goes unrecognized. The rate of PID cannot be determined. The goal is to protect patients and reduce population. The enemy is not physicians with opposing positions on this issue.     

The intrauterine device, pelvic inflammatory disease, and infertility: the confusion between hypothesis and knowledge.

An earlier editorial made many false claims against the IUD and women. In many cases, the author extrapolated experience from the Dalkon Shield to today's IUDs. He even said the modern contraception has not reduced fertility, but data from at least 7 developing countries clearly refute that statement. Moreover he claims that the most female ambition is motherhood. Thus he blamed women for high fertility rates without acknowledging that women in developing countries have little control over fertility. Husbands determine when and how often to have intercourse and whether to use contraceptives or not. Women do not always have access to contraceptives. The author boldly stated that the IUD poses a threat to future fertility because it causes pelvic infections. The real threat is intercourse by which upper genital tract infections are transmitted. It is these sexually transmitted diseases that cause pelvic infections. The studies the author quoted have been found to have considerable bias and/or methodologic flaws. Some studies used as the comparison group women using contraceptive which lower the pelvic infection risk. Contemporary studies find no increased risk of infertility in copper and hormone IUD users, but instead show increased risk for multiple sex partners. Some studies do indicate an increased risk shortly after insertion which is due to insertion instrumentation used. The author even claimed that a Swedish study concluded that IUDs promote pelvic infection in patients with gonorrhea and chlamydia. But the Swedish study found no difference in pelvic infection risk between IUD and non-IUD, nonhormonal contraceptive users. Based on hundreds of millions of woman-years of worldwide experience, WHO claims modern copper and hormone releasing IUDs, when used as directed, may be the most effective and reliable reversible contraceptive method. This editorial based on flawed conclusions and misinformation does an injustice to the IUD and to women.     

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.     

Use of oral contraceptives in Germany: prevalence, determinants and use-associated health correlates. Results of National Health Surveys from 1984 to 1999

OBJECTIVES: To describe oral contraceptive (OC) use, its determinants and use-associated health correlates from 1984 to 1999 in Germany. STUDY DESIGN: Cross-sectional comparison was performed for socioeconomic factors, personal lifestyle and use-associated health correlates between 1862 OC users and 2625 age-matched nonusers identified from five German National Health Surveys. Regression models were used to obtain the determinants of OC use. RESULTS: While in women aged 25-49 years OC use remained nearly constant in the western part of Germany from 1984 to 1999 (17.3-20.1%), it declined greatly in the eastern part from 43.0% in 1991 to 32.3% in 1999. Cross-sectional comparison and regression analysis suggested that OC users did not differ from nonusers in most selected personal and socioeconomic factors. OC users showed generally a better health profile than age-matched nonusers with more satisfaction with health, higher quality of life and no significant difference in history of cardiovascular diseases despite slightly higher prevalence of hypertension and hyperlipidemia that are of little clinical significance. CONCLUSIONS: OC use seems to be generally safe. Whether the better health profiles found in OC users are the results of OC use or effects of healthy users, or both, should be further studied.     

The intrauterine device in modern contraception: Still an actuality?

The intrauterine devices (IUD) is a contraceptive method largely used as an effective, safe and economic method of contraception; IUD efficacy is demonstrated to be about 97%, and copper IUD contraceptive failure frequency is about 0.8% for the first year of use, and this is about 0.1-0.2% for the progestin IUD. IUD benefits are different; it produces a well-defined contraceptive efficacy for long time, is useful for sexual activity and is rather free from common problems. However, IUD utilization is associated with an increasing risk of pelvic infection (0.5%) in the 8 years from initial use, and the common risk of pelvic inflammatory infection (PID) is about one to two cases per year; this risk, for copper IUD users, is 0.2-0.5% per year. The possible side effects of IUD use are: pelvic pain, irregular meshes, infections, bleeding and uterine perforation; we report a uterine perforation due to IUD migration in the Retzius space, diagnosed on transvaginal ultrasonography, confirmed on CT and removed by laparoscopy. In any case, the IUD remains the mainstay of family planning measures in developing countries but, unfortunately, its association with possible serious complications, change the cost-benefit link and restrict its utilization by a large part of the general population.     

Intrauterine devices

Approximately 60 million women use the intrauterine device (IUD) worldwide; however, owing primarily to nonmedical reasons, the IUD is far less popular in the United States. Although the contraceptive mechanism of action is unknown, it appears that spermicidal activity may be important. Overall, the efficacy of the copper devices is quite good, such that the overall lifespan can probably be extended. Possible pelvic infection remains the greatest potential risk, although in properly selected women the risk is quite low. Use of prophylactic antibiotics at the time of insertion may offer additional protection against this risk. Although IUD users may have more nonspecific vaginal inflammation than do other women, the clinical significance is probably limited. Further, users do not appear to have elevated risks for cervical infections. Although menometrorrhagia persists as a potential problem, the mechanism for such bleeding is not well understood. Finally, the retroflexed uterine position does not appear to increase the risk of abnormal outcomes.     

Oral contraceptive use and the risk of chlamydial and gonococcal infections

Oral contraceptive users were compared with nonusers with respect to the rate of cervical infections by Chlamydia trachomatis and Neisseria gonorrhoeae. The comparison was adjusted for differences in demographic and behavioral characteristics between the two groups. The rates of infection among oral contraceptive users were increased by approximately 70% (statistically significant) for both pathogens. Cervical ectopy was implicated in the increased rate of chlamydia but not gonorrhea. Rates of gonorrheal infection differed significantly among oral contraceptive formulations; rates were higher for formulations containing more androgenic progestins.     

IUDs and pelvic infection

The risk of pelvic infection in wearers of IUDs is discussed from the viewpoint of criteria used in epidemiology to indicated cause and effect. There are 3 types of statistical associations in epidemiology: spurious, or false associations; indire ct associations acting through another factor; and causal, by which exposure leads to the outcome. The evidence for IUDs leading to pelvic infection is reviewed using the criteria listed by Hill. First, a large relative risk: reported risks range from 1.5-12, usually 3-5, are not considered due to bias. Second, consistent association across all types of studies: this has been true until recently. Third, specificity of effect, meaning one exposure leads to a single outcome: this is not true for pelvic infection, which is influenced by many factors. Fourth, temporal sequence, meaning the exposure must precede the outcome; although temporal association does not prove causal association. Fifth, biologic gradient or dose-response: in this case, more infections are associated with briefer rather than longer duration of IUD use. Sixth, plausibility: that IUDs could cause infection seem plausible. Seventh, experimental or analogous argument: there are no relevant laboratory models for IUDs in women, nor can IUDs be considered like a foreign body in other tissues. Since PID is sexually transmitted, the literature on IUDs and infection is confounded by use of comparison groups with artificially low infection rates. Diagnosis of PID, and even hospitalization rates in IUD users are inflated because of subjective bias against IUDs with respect to PID, leading to selection bias in epidemiologic studies. Three recent well-designed studies with sexually active controls not using contraceptive methods that protect against STDs show no increase in incidence of PID in IUD users.     

Oral contraceptive use by teenage women does not affect body composition

OBJECTIVE: To assess the effect of oral contraceptive (OC) use during adolescence on body composition parameters and cardiovascular disease risk factors. METHODS: We used 9 years of longitudinal data from 66 non-Hispanic white females who were 12 years old at study entry in 1990, and who were subsequently classified either as OC users or nonusers. The OC users (n = 39) used OCs for a minimum of 6 months, were still using at age 21, and had used OCs, on average, for 28 months. The nonusers (n = 27) never used OCs. Individuals who started and then stopped using OCs before age 21 or used OCs for less than 6 months were excluded from these analyses. Cardiolipoprotein profiles were obtained from fasting blood samples (from age 16 to 21), and body composition measurements were made by dual energy x-ray absorptiometry (from age 12.5 to 21). Longitudinal models were used to examine changes in body composition patterns and in cardiolipoprotein patterns. RESULTS: Between ages 12.5 and 21, gains by OC users and nonusers in height, weight, body mass index (BMI), and percent body fat were not significantly different. However, between ages 16 and 21, the OC users had significantly greater increases in total serum cholesterol, serum low-density cholesterol, and serum triglycerides than did the nonusers. CONCLUSION: The use of OCs in young women is associated with less favorable blood lipid patterns, but is not associated with weight gain or increased body fat. The long-term effects of the alteration in the lipid profiles are unknown.     

Follow-up visits after IUD insertion. Are more better?

OBJECTIVE: To determine whether frequent follow-up visits for intrauterine device (IUD) users prevents the development of pelvic inflammatory disease (PID). STUDY DESIGN: A prospective, cohort design was used to study 1,713 women who received an IUD in 1992 in Mexico. They were divided into two different follow-up regimens and were asked to return for either two or four revisits in the first year after insertion. The main outcome measures included incidence of PID and asymptomatic/symptomatic lower genital tract infections. Time to detection of lower genital tract infections was measured in a proportional hazards regression model; this analysis achieved 90% power to detect differences between the regimens. RESULTS: The two regimens were nearly identical in terms of PID incidence. The incidence rates for asymptomatic and symptomatic lower genital tract infection were slightly higher in the four-visit regimen; however, the incidence rate ratios were not statistically elevated: 1.41 (0.77-2.56) and 1.23 (0.67-2.27), respectively. In the regression, the variable denoting follow-up regimen was not associated with time to detection of lower genital tract infection. CONCLUSION: More follow-up visits for IUD users provide no benefit in terms of preventing PID or progression toward the disease.     

Genitourinary infection prevalence among women who used an intrauterine device or oral contraceptives

Purpose

The study aimed at investigating genitourinary infection prevalence among women who used an intrauterine device (IUD) and oral contraceptives (OC) in relation with their socio-demographic characteristics.

Methods

The study was conducted at the Mother and Child Health and Family Planning center between October 2011 and February 2012 and included 81 women who used IUD, 84 who used OC, and 84 who did not use artificial contraceptive methods (coitus interraptus).

Results

It was found that there was a difference between the three groups in terms of urinary system infection (X ² = 9.85, p = 0.000) and genital infection (X ² = 8.29, p = 0.001). It was also observed that urinary infection was more common in the OC group, whereas genital infection was more common in the IUD group. In urinary culture, it was seen that Enterobacter species was the most common microorganism among the group who used an IUD, while Escherichia coli was the most common microorganism in the group who used OC and the control. In vaginal cultures, Candida albicans was determined to be the first isolated microorganism among the group who used OC, IUD, and the control.

Conclusion

It is believed that the most significant reason for genitourinary infections among women was inadequate hygiene practices rather than use of different contraception methods.     

Health risks of intrauterine contraception (author's transl)

Uterine perforation, intrauterine and ectopic pregnancy, pelvic infection, and fertility problems after removal of the IUD are among recognized or potential health risks of IUD use. The frequency of uterine perforation varies according to type of IUD, with estimates of cervical and uterine perforation respectively ranging from 0 in 4122 Saf-T-Coil insertions to 1.5 and .3/1000 insertions of the Copper T. Data on perforations and their treatment and sequelae are however incomplete and unsatisfactory. The structure of the IUD, the rigidity of the applicator, the size and position of the uterus and the time of insertion relative to delivery or abortion, and the physician's technique and experience are all related to the incidence of perforation. Reported pregnancy rates/100 woman years vary from 5.3 for the Lippes Loop A to 1.6 for the Copper 7 Gravigard among nulliparous users. Disparities result from inherent fecundity differences in the populations studied, the age-parity composition of the population, sociocultural factors related to timing and frequency of coitus, and methods of data analysis. Spontaneous abortion rates for intrauterine pregnancies with IUDs range from 23.5-52.9% depending on whether the device is in place, but rates do not differ greatly from those of diaphragm users if the IUD is removed, even during pregnancy. The IUD does not seem to increase the risk of congenital anomaly. Although evidence and opinion on the question are divided, the use of an IUD apparently does not by itself increase the risk of ectopic pregnancy. Later fertility does not seem to be affected: 80-90% of women discontinuing IUD use to become pregnant do so within 1 year. Pregnancy rates appear to be comparable to those of women discontinuing diaphragm use. Although evidence of a greater risk of pelvic inflammatory disease among IUD users has been observed, the extent of the added risk if any is unclear because of diagnostic and methodological problems. In comparison to other reversible methods of contraception, the rates of failure, and of mortality resulting from use of the IUD or indirectly from failure of the IUD, are low. Patients should however be carefully screened and informed of the risks and symptoms.     

Fertility and characteristics of ovulation after discontinuing oral contraception

A brief review of the literature is the basis for this discussion of residual effects of oral contraceptives (OCs) on fertility and the quality of ovulation after pill use is terminated. A 1982 study of the delay to conception attempted to avoid methological difficulties of earlier studies by comparing previous contraceptive usage among 7000 women hospitalized for childbirth. The analysis showed that the monthly percentage of pregnancies after OC use was significantly decreased for the 1st 3 months compared to levels in former IUD and diaphragm users. 13 months after OCs, 24.8% of OC users still had not conceived, compared to 12.4% if IUD and 8.5% of diaphragm users. Post-pill amenorrhea of longer than 6 months occurs in about 1% of cases. It is now agreed that post-pill amenorrhea is rare, nonspecific, and of multifactorial etiology. The previous existence of menstrual irregularity, stress, psychological troubles, malnutrition, and anorexia are particularly significant. OC use seems to mask the natural occurrence of secondary amenorrhea rather than to cause it. The most careful of available studies document that, although OC use may because of its estrogen content reveal an unsuspected prolactinemia, there is no increase in prolactinemia among OC users. A consensus exists that, excluding patients developing amenorrhea due to ovarian insufficiency, post-pill amenorrhea responds to ovulation inducing treatment exactly as do amenorrheas with no history of pill use. In cases of conception after failure of OCs and continued treatment with OCs, the aging of sperm or hypermaturation of ova at the time of fertilization is accompanied by a very slight increase in the proportion of male fetuses. The teratogenic risk appears to be negligable among former OC users and perhaps slightly greater if OCs, hormonal tests, or supplementary hormonal therapy are continued during pregnancy. The increased risk is not even seen in many studies and does not appear to indicate pregnancy termination as a general rule.