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Purpose of Review: Pelvic inflammatory disease (PID) is a common and serious reproductive health disorder and disease rates remain unacceptably high among adolescent girls and young adult women in the United States. Despite data demonstrating that women experience major adverse health outcomes after PID, national recommendations for management of adolescents have become increasingly less cautious in an era of cost-containment. In this review, we take an alternative look at published data on adolescents with PID to frame the next steps for optimizing management for this vulnerable population., Recent Findings: Several findings emerge from review of the literature. First, there is limited evidence to guide the best practice strategies for adolescents with PID due to low enrolment of early and middle adolescents in national trials. Second, adolescents and adult women in the United States receive suboptimal treatment regimens per Centers for Disease Control and Prevention (CDC) standards. Third, available evidence suggests that adolescents are at an increased risk for poor adherence to CDC recommendations for self-care, reacquisition of sexually transmitted infections (STIs) and PID, and subsequent adverse reproductive health outcomes., Summary: Efforts to develop and integrate adolescent-focused, evidence-based strategies for PID management and prevention of subsequent STIs and recurrent PID are warranted.

Pelvic inflammatory disease (PID) is a common disorder affecting sexually active adolescents. The Centers for Disease Control and Prevention (CDC) and European CDC report Chlamydia trachomatis as the most common sexually transmitted infection and one of the main etiological agents causing PID. C. trachomatis' and PID's high prevalence may be attributed to multiple factors including high-risk sexual behaviors, sensitive laboratory diagnostics (polymerase chain reaction), and the introduction of chlamydia screening programs. The pathogenesis of C. trachomatis infection is complex with recent data highlighting the role of toll-like receptor 2 and four in the mediation of the inflammatory cascade. The authors review the etiology of the disease, explore its pathogenesis, and discuss a variety of strategies that may be implemented to reduce the prevalence of C. trachomatis including: (a) behavioral risk reduction, (b) effective screening of asymptomatic females, (c) targeted male screening, (d) implementation of a sensitive, rapid, self-administered point-of-care testing, and (e) development of an effective vaccine.

For most women, intrauterine contraceptive devices (IUCD) are a safe option. Upper genital tract infections (pelvic inflammatory disease, PID) occur when pathogenic microorganisms ascend from the cervix and invade the endometrium and the fallopian tubes, causing an inflammatory reaction. Evidence-based recommendations regarding intrauterine contraception and risk of infection were presented at the Congress of the European Society of Contraception, in Prague, 2008: A clinical history (including sexual history) should be taken as part of the routine assessment for intrauterine contraception to identify women at high risk of sexually transmitted infections (STI); if appropriate a test should be offered; if symptoms or signs are present, appropriate diagnostic tests should be done, results awaited, necessary treatment completed, and IUCD insertion postponed until resolution. Prophylactic antibiotics are not recommended (evidence level II-3). STI screening is not routinely recommended. PID among IUCD users is most strongly related to the insertion process and to the background risk of STI (evidence level II-2). Conditions which represent an unacceptable health risk if an IUCD is inserted (WHO Medical Eligibility Criteria, MEC, Categories 3-4) are current PID, current purulent cervicitis, chlamydial or gonorrheal infection. For continuation as well as initiation, WHO MEC categories 3-4 are allotted to women with known pelvic tuberculosis, puerperal sepsis and septic abortion.

Sexually transmitted infections (STIs) are an important public health challenge in the United States. Primary care clinicians can contribute to decreasing these largely preventable causes of morbidity and mortality by integrating routine screening, testing, counseling, treatment, and partner management of STIs into their practice. Newer tests for chlamydia and gonorrhea that can be performed on urine specimens allow screening without a pelvic examination. The most recent edition of the Centers for Disease Control and Prevention sexually transmitted disease treatment guidelines provides an evidence-based, reliable, and convenient set of recommendations for treating and caring for patients who have STIs.

Objectives: To prevent pelvic inflammatory disease (PID), some experts recommend screening for sexually transmitted infection (STI) every 12 months, with more frequent screening suggested in higher-risk women. Nevertheless, the time from STI acquisition to PID development, possibly an important factor to consider in screening interval choice, is unknown and its influence on the effectiveness and cost-effectiveness of screening is unclear., Methods: Using a Markov model, we estimated PID cases averted and the incremental cost-effectiveness resulting from 6- or 12-month screening strategies for high-risk young women (6%/year infection risk, 2.8%/year PID risk with 12-month screening) while varying PID development time from 1 to 12 months after initial infection. Lower-risk women and alternative parameter values were examined in sensitivity analyses., Results: Relative to 12-month screening, 6-month screening decreases PID cases from 6.0% (1 month development time)to 19.4% (12 months); the incremental cost per quality-adjusted life-year (QALY) gained compared with the other strategies varies from $16,600 (12 months development time) to $31,800 (1 month) for high-risk women. In lower-risk women, every 6-month screening is more economically unfavorable, with greater costs per QALY gained at shorter PID development time., Conclusion: From a cost-effectiveness standpoint, uncertainty about PID development time is not a significant factor in choosing a screening interval in high-risk women, but could be important in lower-risk groups. Significant increases in PID cases averted occur with more frequent screening when PID development time is lengthened, which may allow estimation of this interval through the use of more sophisticated modeling techniques.

Sexually transmitted diseases (STDs) impose a tremendous health burden on women, and adolescent females are the group at the highest risk. Universal annual screening of all women younger than 25 years of age has been a best practice recommendation since 1997. When implemented, such screening leads to a decrease in disease prevalence and of serious sequelae, such as pelvic inflammatory disease (PID). However, STD screening rates in actual clinical practice fail to approach recommendations. In this review, we summarize findings from recent surveys of providers and adolescents, discuss barriers to STD screening, and offer strategies for individual clinicians to improve STD screening rates in practice.

Persons rely on health care providers to make diagnostic and therapeutic decisions based on the most current information. With areas of practice changing rapidly, providers are challenged to keep abreast of new and changing treatment guidelines. The new Centers for Disease Control and Prevention (CDC) 2002 Sexually Transmitted Disease (STD) Treatment Guidelines provide clinical guidance in the appropriate assessment and management of STDs. This article reviews recent changes in the STD Treatment Guidelines for the most common disease entities and their sequelae encountered by women's health practitioners. The changes noted in this article include new screening recommendations, use of new diagnostics, new treatment algorithms, and changes in therapeutic regimens.

Background and Goal: There is little information in Manitoba on the utilization of drugs for sexually transmitted disease (STD) treatment and the extent to which physicians comply with STD screening and treatment guidelines. This study was undertaken to provide such information to inform policy and program development., Methods: Physicians providing STD care were asked to complete a simple record for each new STD index client or contact seen. This information was subsequently linked with data from provincial diagnostic and treatment databases., Results: Between October 1997 and September 1998, there were 2535 reports of STD treatments. Only about 25% of drugs provided by the provincial health department to physicians for STD treatment could be accounted for on the basis of the treatment reports received. Seventy-four percent of all treatments provided were presumptive ones for urethral or cervical infection or pelvic inflammatory disease (PID), and 14.4% of these were associated with subsequent positive tests for Chlamydia trachomatis or Neisseria gonorrhoeae. About three quarters of presumptive treatments were in compliance with provincial guidelines, as were most etiology-based treatments for chlamydial infection and 72% of etiology-based treatments for gonorrhea. Noncompliance with guidelines was commonly due to presumptive treatment that covered only C trachomatis, nonrecommended treatment for N gonorrhoeae, and incorrect treatment of PID. Only about 25% of women and 4% of men aged 15 to 24 years who visited a physician in 1997 were tested for C trachomatis., Conclusion: Increased educational efforts are required to improve physician compliance with STD screening and treatment guidelines, as well as ensure the appropriate use of STD drugs provided. Opportunities are being missed for screening for C trachomatis among young people, the majority of whom are seen regularly by a physician.

Objective: To determine the most cost-effective method of screening for chlamydia and gonorrhea to prevent pelvic inflammatory disease (PID) in asymptomatic sexually active adolescent females., Design: Cost-effectiveness decision analysis comparing pelvic examination with cervical screening (the current national standard) with a model of urine screening with ligase chain reaction testing for Chlamydia trachomatis and Neisseria gonorrhoeae., Methods: Four strategies using decision analysis were compared for a potential cohort of 100000 asymptomatic sexually active young women: (1) pelvic examination screening in 100%; (2) urine screening in 100%; (3) actual predicted pelvic examination screening in 70%; and (4) actual predicted urine screening in 90%. Assumptions and costs were generated from published sources., Main Outcome Measures: Cases of PID prevented per year and cost to prevent a case of PID., Results: A total of 1750 cases of PID would be predicted to occur per year with no screening. Strategy 1 would prevent the most cases of PID (1283) at a mean cost of $10230. Strategy 2 would prevent 1215 cases of PID at a mean cost of $5093. The marginal cost to prevent an additional case of PID by strategy 1 is $101454. Strategy 3 would prevent 898 cases of PID and 1093 cases of PID would be prevented with urine screening in strategy 4., Conclusion: Urine-based ligase chain reaction screening is the most cost-effective strategy to detect chlamydial and gonococcal genital infection in asymptomatic sexually active adolescent females and, owing to ease of implementation, the most likely to prevent the greatest number of cases of PID.

These guidelines for the treatment of patients who have sexually transmitted diseases (STDs) were developed by CDC staff members after consultation with a group of invited experts who met in Atlanta on February 10-12, 1997. The information in this report updates the "1993 Sexually Transmitted Diseases Treatment Guidelines" (MMWR 1993;42[no. RR-14]). Included are new recommendations for treatment of primary and recurrent genital herpes and management of pelvic inflammatory disease; a new patient-applied medication for treatment of genital warts; and a revised approach to the management of victims of sexual assault. Revised sections describe the evaluation of urethritis and the diagnostic evaluation of congenital syphilis. These guidelines also include expanded sections concerning STDs among infants, children, and pregnant women and the management of patients who have asymptomatic human immunodeficiency virus infection, genital warts, and genital herpes. Guidelines are provided for vaccine-preventable STDs, including recommendations for the use of hepatitis A and hepatitis B vaccines.

Today "safe sex" means protection from both unintended pregnancy and sexually transmitted disease and human immunodeficiency virus. These parallel complications of sexual activity have serious biologic and clinical sequelae that should be considered at the time of contraceptive selection. In addition, there is ongoing debate regarding potential interactions between antibiotic intervention and contraceptive steroids. This article assesses the impact of hormonal contraception, spermicides, barrier methods, intrauterine devices, and douching on the pathogenesis of sexually transmitted disease and the human immunodeficiency virus infection. It discusses the direct and indirect effects of contraception methods on clinical physiology and host immune responses while also considering the possible consequences on maternal and infant health if pregnancy results from the use of ineffective contraception. Counseling and care for both family planning and infectious disease protection must be provided to all sexually active individuals.

The control of sexually transmitted diseases (STD) will reduce the prevalence of pelvic inflammatory disease (PID). In most developing countries, treatment services are limited, coverage of the infected female population is inadequate and women seeking treatment are likely to be mismanaged. Family planning clinics do not usually provide routine screening for non-pregnant women. Screening only at family planning clinics would result in failure to treat some high-risk individuals, especially unmarried adolescents. The use of simplified protocols in the community has been recommended, but these may underestimate the problems of contact tracing, provide no systematic screening and induce passivity in the patient. For pregnant women, STD control has targetted syphilis, which does not cause PID. An integrated service for the management of reproductive health is required, and the development of women's clinics is suggested, using well-trained nurses and affordable technologies.

The problems in surveillance of sexually transmitted disease (STD) in Africa are numerous and are based mainly on socioeconomic barriers. Policies for controlling STD are either inadequate or nonexistent in many African countries. Gonococci are becoming increasingly insusceptible to penicillin and other drugs because of widespread use of inadequate therapy. Gonorrhea is recognized as the major pathogen of pelvic inflammatory disease in Africa. The magnitude of the PID problem is so great that current efforts are directed at case treatment rather than surveillance and control. The formation of the African Union Against Venereal Diseases and Treponematoses is an important step, and its suggestions and resolutions form a sound basis for improved STD control in Africa.

In South America, the number of women at risk for gonococcal pelvic inflammatory disease has increased greatly along with the incidence rates for gonorrhea. Further information is needed on the epidemiologic aspects of gonorrhea and PID in order to develop programs for optimal control of sexually transmitted disease (STD). We think that the control of STD, including PID, requires improvement of four basic factors: professional training in STD, management of STD by all levels of health care services, laboratory diagnostic services, and public education in STD.

The national gonorrhea control program has expanded since its inception in 1972 and now reflects new information and program evaluations. Initial program objectives to reduce the incidence of disease and the resistance of gonococci to antibiotics have been expanded to reduce the occurrence of pelvic inflammatory disease and to limit the sequelae of PID. The changes since 1972 in the national venereal disease control program have increased the number of people helping control programs and have enhanced our ability to control other sexually transmitted diseases.

Little published data are available on pelvic inflammatory disease in the Far East. Measures available to control gonorrhea in the region are reviewed. The rising incidence of penicillinase-producing Neisseria gonorrhoeae in Singapore and the Far East and its implications concerning the pathogenesis of PID are discussed.