Diagnosis Of Pelvic Inflammatory Disease Research Articles

Intrauterine device use in an urban university clinic: safety of use in a population at high risk for sexually transmitted infections

ObjectiveThe objective was to describe infection rates after intrauterine device (IUD) placement at an urban teaching hospital that did not restrict IUD eligibility based on risk factors for sexually transmitted infections (STIs). MethodsWe reviewed charts of patients undergoing IUD placement at the University of Chicago obstetrics and gynecology resident clinic from July 2007 to June 2008 (n=283). The primary outcome was diagnosis of pelvic inflammatory disease (PID) within 12 months. ResultsAlmost half (49.5%) of patients reported a history of any STI. Two patients (0.7%) were diagnosed with PID. ConclusionPostplacement infection in this unrestricted population was infrequent and comparable to reported rates in previous studies.

Clinical versus laboratory screening for sexually transmitted infections prior to insertion of intrauterine contraception among women living with HIV/AIDS: a randomized controlled trial.

Does laboratory testing after syndromic screening for sexually transmitted infections (STIs) reduce the rate of intrauterine contraception (IUC) removal among women living with HIV/AIDS (WLHA)? Additional laboratory testing after syndromic screening for STIs did not affect the likelihood that a woman would remove an IUC immediately or within 1 year of IUC use or the frequency of post-insertion unscheduled clinic visits. In low-risk WLHA, the incidence rate of IUC removal is low with or without laboratory testing. Fear of infectious morbidity remains an obstacle to uptake of IUC by WLHA. The value of laboratory testing after syndromic screening for STI before the insertion of IUC remains uncertain. We enrolled WLHA from 2 September to 6 December 2013 and followed them up to 31 December 2014. After syndromic screening, 703 women free of STIs were randomized to either additional laboratory screening or no additional screening for STI before IUC insertion. The randomization sequence was generated by an independent statistician and randomization numbers placed in opaque sequentially numbered sealed envelopes. All women randomized had an IUC inserted and in all 672 participants completed the 1-year follow-up. The study staff who followed up the participants were blinded to the study allocation groups. Incidence rate ratios (IRRs) were used to compare the incidence rates of IUC removal, unscheduled clinic attendance and IUC continuation between the two groups. Women eligible to participate were 18-49 years old at study entry, in a relationship with a male partner, wanted to avoid pregnancy for at least 1 year and were undergoing HIV/AIDS care at Mulago Hospital, Uganda. Participants completed a baseline questionnaire and up to four follow-up questionnaires until discontinuation of IUC, loss to follow-up or end of study observation after 12 months. The rate of IUC removal was 8.8% (29/331) in the no additional screening group and 8.0% (27/341) in the additional laboratory screening group [IRR 1.1 (95% CI 0.63-1.93)]. Unscheduled clinic attendances were similar in the two groups at 1 year of IUC insertion: 13.6% (45/331) in the no additional screening group and 12.3% (42/241) in the additional laboratory screening group. During the 1-year follow-up, only five women, three from the no additional screening group and two from the additional laboratory screening group, developed pelvic inflammatory disease (PID), as defined by established diagnostic criteria. We were not able to carry out STI risk assessment directly from the men thus women with high-risk partners could have been included in the study and this may be responsible for the lack of a demonstrable effect of additional laboratory screening on incidence rates of IUC removals and unscheduled clinic attendance. The diagnosis of PID was based on clinical signs and symptoms; therefore, subclinical PID could have been missed. Among WLHA, the incidence rate of IUC removal is low and IUC continuation high. Syndromic screening for STIs could be sufficient in indentifying WLHA who are suitable for IUC use. However, our findings are only generalizable to women in HIV/AIDS care who have access to good follow-up. The study was supported by Medical Education for Equitable Services to all Ugandans, a Medical Education Partnership Initiative grant number 5R24TW008886 from the office of Global AIDS Coordinator and the US Department of Health and Human Services, Health Resources and Services Administration and National Institutes of Health. Additional funding was from the Swedish International Development Agency, Swedish Research Council (SIDA/VR). The authors have no competing interests to declare. This trial was registered at Pan African Clinical Trial, Registry. PACTR 201308000561212.

Predictive Markers of Tubo-Ovarian Abscess in Pelvic Inflammatory Disease

Background/Aims: The purpose of this study was to identify predictive markers for tubo-ovarian abscess (TOA) through a comparison of clinical and laboratory data in patients diagnosed with pelvic inflammatory disease (PID). Methods: We reviewed the medical charts of 499 females who were admitted to hospital with clinical, surgical, imaging-based diagnoses of PID between 2001 and 2011. The patients were divided into the following two groups: (1) PID with TOA and (2) PID without TOA. Results: The TOA and non-TOA groups were comprised of 69 and 430 females, respectively. Mean age, history of intrauterine device (IUD) insertion and inflammatory markers, including erythrocyte sedimentation rate, C-reactive protein (CRP) and CA-125 levels, were higher in the TOA group than the non-TOA group. Independent factors that predicted TOA were older age, IUD insertion, increased CRP and CA-125, and chlamydia infection. CA-125 was found to have the highest predictive value for TOA. TOA size was associated with increased surgical therapy compared to patients with smaller abscesses. Conclusions: Increased age, IUD insertion, chlamydia infection, and increased CRP and CA-125 level were the independent factors predictive of TOA in acute PID. These predictive values will be expected to help decrease gynecological morbidity by early diagnosis and appropriate treatment of TOA.

Intrauterine contraception in nulliparous women: a prospective survey

BackgroundIntrauterine contraception is a first-line option for young women, yet relatively few prospective studies have been performed in nulliparous women using currently available devices, and many providers are still reluctant...

Update on pelvic inflammatory disease

Pelvic inflammatory disease (PID) is the major cause of tubal infertility, the risk of which increases markedly after recurrences, which are common. It also increases the risk of ectopic pregnancy. Diagnosis is difficult and treatment may not prevent tubal damage and scarring so prevention or prompt treatment of sexually transmissible infection (STI) that often precedes it is a priority. The diagnosis of PID is usually based on a history of pelvic pain and evidence of cervical and adnexal tenderness but symptoms are often non-specific or absent. There is poor correlation between clinical and laparoscopic findings. In a recent study only 20% of women with pelvic pain (and only 55% of those considered, clinically, to have PID) had laparoscopic evidence of active salpingitis. Identifying the microbiological causes is also difficult; the predominant pathogens are Chlamydia trachomatis (by far the most common), Neisseria gonorrhoeae, Mycoplasma genitalium and/or mixed endogenous vaginal bacteria (the latter especially when PID is associated with genital trauma e.g., pregnancy termination or complications). Investigations of suspected PID should include urine nucleic acid tests for major STI pathogens and endocervical cultures for predominant facultative bacteria, including N. gonorrhoeae . However, cervical microbiology does not always reflect tubal flora and therapy is usually empirical.

Comparison of severe pelvic inflammatory disease, pyosalpinx and tubo-ovarian abscess.

Inflammation of the upper genital tract causes pelvic inflammatory disease (PID), which may be complicated by pelvic abscesses, such as pyosalpinx and tubo-ovarian abscess (TOA). This study aimed to determine the clinical differences between pyosalpinx and TOA in patients with PID. We retrospectively evaluated 458 female patients who were admitted to Hallym University Kang Dong Sacred Heart Hospital for a clinical diagnosis of PID from 1 January 2007 to 30 April 2012. Sociodemographic, clinical and laboratory data were compared among the non-abscess, pyosalpinx, and TOA groups. We identified 110 patients (24%) diagnosed with pelvic abscess associated with PID, including 34 with pyosalpinx and 76 with TOA. The pyosalpinx group had shorter hospital stays (P = 0.007), lower C-reactive protein levels (P = 0.015), smaller mass sizes (P < 0.001), and fewer surgical interventions (P < 0.001) than the TOA group. Pyosalpinx is a less severe form of PID that leads to shorter hospital stays and more favorable outcomes than TOA.

Management of pelvic inflammatory disease

Pelvic inflammatory disease (PID) refers to a variety of inflammatory conditions involving the upper genital tract in females. This article aims to increase knowledge of the management of mild to moderate PID by nurse prescribers working in sexual health. An overview of how to identify PID and the types of bacteria that can cause it is provided. The article provides an understanding of the process required to make a diagnosis of PID, and highlights other conditions that may cause similar symptoms. The pharmacological options in treating non-complex mild to moderate presentations of PID are covered.

Increased plasma soluble CD40 ligand concentration in pelvic inflammatory disease

BackgroundThe role of soluble CD40 ligand (sCD40L) in pelvic inflammatory disease (PID) remains unclear. We sought to determine whether sCD40L was an efficient serum marker as with WBC and CRP in PID patients. MethodsEnzyme-linked immunosorbent assay was used to measure the plasma levels of sCD40L before and after routine protocol treatments in sixty-four PID patients and seventy healthy controls. ResultsThe level of plasma sCD40L (pg/ml) was significantly elevated in PID patients (1632.83±270.91) compared to that in normal controls (700.33±58.77; p=0.001) and decreased significantly as compared to that in the same patients (928.77±177.25; p=0.0001) after they received treatment. The concentration of sCD40L was significantly correlated with the level of plasma C-reactive protein (CRP) in the blood (r=0.202, p=0.01, n=134). When the cutoff level of plasma sCD40L levels was determined to be 1612.26pg/ml based on ROC, the sensitivity, specificity, and the area under the curve of plasma sCD40L level for predicting PID were 0.26, 0.97, and 0.58 (95% confidence interval: 0.48–0.68), respectively, while the adjusted odds ratio (AOR) with their 95% CI of plasma sCD40L for PID risk was 7.09 (95% CI=1.14–43.87, p=0.03). ConclusionsThe expression of plasma sCD40L was increased in patients with PID and detection of plasma sCD40L could be useful for the diagnosis of PID.

A self-assessed questionnaire can help in the diagnosis of pelvic inflammatory disease.

Pelvic inflammatory disease (PID) is often responsible for acute pelvic pain, yet its clinical diagnosis is difficult. The aim of this study was to develop and validate prediction rules for the diagnosis of PID in patients seen for acute pelvic pain, based solely on a self-assessed questionnaire. From September 2006 to April 2008, 499 consecutive patients presenting at the gynecology emergency departments of 5 hospitals for acute pelvic pain completed a Self-Assessment Questionnaire for Gynecological Emergencies. Seventy-three were identified as having a PID. Two-thirds of the database was randomly selected for the derivation of the prediction rules, and the other third was used for internal validation. We developed 2 scores, one that rules out a diagnosis of PID and one that predicts PID, based on multiple logistic regression with jackknife estimates. These scores were then validated with the validation data set. Four variables were independently associated with PID: scattered pain radiation and/or diffuse pain, insidious pain, peritoneal irritation, and abnormal vaginal discharge. They were used to create a sensitive prediction model that rules out PID. Four other variables were used to build another model that predicted PID with high specificity: abnormal vaginal discharge, bilateral pelvic pain, constipation, and presence of an intrauterine device. The probability of PID for the patients in the low-risk group was 1.1% (95% confidence interval, 0.03-5.8), and the probability of PID in the high-risk group was 55% (95% confidence interval, 31.5-76.9). These 2 prediction rules that classify patients in low risk or high risk of PID, based on simple items collected by a self-assessed questionnaire that are composed only of case history and autodescription of the pain, may prove useful for diagnosing or ruling out PID in patients with acute pelvic pain.

A cross-sectional study showing differences in the clinical diagnosis of pelvic inflammatory disease according to the experience of clinicians: implications for training and audit

ObjectivesPelvic inflammatory disease (PID) generates diagnostic difficulty even for experienced doctors. Junior doctors and nurses also assess women with symptoms suggestive of PID. We aimed to determine if and how...

May mean platelet volume levels be a predictor in the diagnosis of pelvic inflammatory disease?

Our aim in this study was to investigate whether mean platelet volume (MPV) value could be used as an early marker to predict pelvic inflammatory disease (PID). Overall, 44 patients with PID and 44 healthy women were included in the study. The control group consisted of 44 women who applied to the clinic for a routine gynaecological check-up, without chronic disease or a history of medication use. Owing to the fact that it would affect thrombocyte function, women who have the following conditions were excluded from the study: women who were taking anticoagulant therapy, oral contraceptives, nonsteroid anti-inflammatory medications and who had chronic diseases. The leukocyte count, platelet count, neutrophil ratio and MPV values were collected from PID and the control group. C reactive protein values of patients with PID were also noted. MPV values in patients with PID were lower than those in the control group. This reduction in MPV is statistically significant when the PID patient group is compared with the control group (p < 0.001). A negative correlation was discovered between platelet count and MPV values (p = 0.019, r = - 0.425). Receiver-operating curve analysis pointed out that MPV has greater area under curve value than neutrophil rate, leukocyte and platelet count (0.73, 0.64, 0.72 and 0.49 respectively). Since the MPV value was significantly decreased in patients with PID, it may serve as an additional and even more valuable marker than leukocyte count in the diagnosis of PID.

Point-of-care testing for chlamydia and gonorrhoea: implications for clinical practice.

ObjectivesPoint-of-care (POC) testing for chlamydia (CT) and gonorrhoea (NG) offers a new approach to the diagnosis and management of these sexually transmitted infections (STIs) in remote Australian communities and other similar settings. Diagnosis of STIs in remote communities is typically symptom driven, and for those who are asymptomatic, treatment is generally delayed until specimens can be transported to the reference laboratory, results returned and the patient recalled. The objective of this study was to explore the clinical implications of using CT/NG POC tests in routine clinical care in remote settings.MethodsIn-depth qualitative interviews were conducted with a purposively selected group of 18 key informants with a range of sexual health and laboratory expertise.ResultsParticipants highlighted the potential impact POC testing would have on different stages of the current STI management pathway in remote Aboriginal communities and how the pathway would change. They identified implications for offering a POC test, specimen collection, conducting the POC test, syndromic management of STIs, pelvic inflammatory disease diagnosis and management, interpretation and delivery of POC results, provision of treatment, contact tracing, management of client flow and wait time, and re-testing at 3 months after infection.ConclusionsThe introduction of POC testing to improve STI service delivery requires careful consideration of both its advantages and limitations. The findings of this study will inform protocols for the implementation of CT/NG POC testing, and also STI testing and management guidelines.

Intérêt des prélèvements bactériologiques endocervicaux en urgence ?

ObjectiveTo estimate the diagnosis profitability of endocervical specimen (ES) within the framework of a teaching gynecological emergency department by studying the circumstances of realization and its bacteriological results. Patients and methodsWe included in our study all the patients who had a gynecological exam with an ES during a consultation in our gynecological teaching emergency department of Tours between January 1st, 2012 and December 31st, 2012. We estimated the diagnosis profitability of realization of the ES (positivity rate within the population with ES, diagnosis correction in case of pelvic inflammatory disease). ResultsOver the study period, 614 (12.4%) women consulting in our emergency department had an ES, which was positive among 102 (16.6%) of them, and a diagnosis of pelvic inflammatory disease in 64 patients. ES had a higher pertinence in case of abdominal pain and a lesser one in case of pregnancy for whom ES realisation must be limited. The diagnosis correction due to ES was observed in 46.8% of pelvic inflammatory disease. ConclusionThe diagnostic profitability of the endocervical specimen in our emergency department was low, taking into account the whole cohort, but ES permitted to correct the diagnosis in about half of diagnosed pelvic inflammatory diseases. The endocervical specimens seem to have no profit in pregnant women.

Diagnosis and Treatment of Pelvic Inflammatory Disease

INTRODUCTION: The Centers for Disease Control and Prevention (CDC) publishes recommendations for the diagnosis and treatment of pelvic inflammatory disease (PID) every 4 years; however, it is unclear whether health care providers adhere to guidelines. This study will determine the rate of clinician compliance with CDC recommendations. METHODS: The Contraceptive CHOICE Project is a prospective cohort study with 9,256 participants in the St Louis region. This substudy is a retrospective chart review of participants within CHOICE who reported a diagnosis of PID in follow-up surveys. Participants were included if they had a confirmed diagnosis of PID through medical records, obtained consent to medical record release, and records were received. Medical records were reviewed and we collected demographics, characteristics, symptoms, and signs at the time of the visit, physical examination findings, diagnostic testing, and prescribed treatment. RESULTS: There were 112 participants who reported being diagnosed with PID on follow-up phone interview (1% CHOICE participants). Eleven participants did not have a recorded diagnosis of PID, and 38 patients did not release their medical records, leaving 63 (56.3%) participants. Abdominal pain was the most common symptom (88.9%) and most patients (77.8%) were found to have at least one of the three minimal requirements for diagnosis of PID. One third of participants (33.3%) received treatment with the recommended regimens. CONCLUSIONS: More than three fourths of patients met CDC minimal criteria for PID; however, only one third of clinicians adhered to CDC treatment. Further education efforts should inform clinicians of evidence-based recommendation for PID therapy.

Diagnosis of pelvic inflammatory disease (PID): intra-operative findings and comparison of vaginal and intra-abdominal cultures

Pelvic inflammatory disease (PID) is frequent in adolescents and younger women. Diagnosis is usually based on the clinical findings, and the threshold for empiric antibiotic therapy should be low. However, at least in cases of resistance toward therapy or deterioration of symptoms, laparoscopic evaluation can be helpful. We searched the hospital charts for in-house patients who were treated for PID or tubo-ovarian abscess between 2007 and 2010. In cases with both vaginal and intra-abdominal bacterial cultures, results of those were compared. 73 patients with suspected PID or tubo-ovarian abscess were included. Median patients' age was 40 years (18-88), 18 of 73 (24.7 %) patients had an IUD at the time of consultation. 58 patients underwent laparoscopy or laparotomy. In 41 patients (70.7 %) tubo-ovarian abscess could be confirmed, four patients had differential gynecologic diagnoses, and two patients appendicitis. In vaginal swabs, most frequent bacteria were Streptococcus sp. (28.5 %), Escherichia coli (22.2 %), Enterococcus faecalis (15.9 %), and Staphylococcus sp. (9.5 %). In eight patients (11 %) Chlamydia trachomatis could be found, there was no case of Neisseria gonorrhea. In 33 patients both vaginal and abdominal cultures were available. In nine cases (27.3 %), identical bacteria could be found, however, 11 cases (33.3 %) showed different results. In severe cases of PID, laparoscopic evaluation and taking an intra-abdominal bacterial culture are helpful for the confirmation of diagnosis, accurate microbiologic testing and specific therapy.

The sensitivity and specificity of transvaginal ultrasound with regard to acute pelvic inflammatory disease: a review of the literature

This review aims to sum up current knowledge on the sensitivity and specificity of ultrasound features suggestive of acute pelvic inflammatory disease (PID). A PubMed database search was undertaken, using the MeSH terms "(pelvic inflammatory disease or salpingitis or adnexitis) and ultrasonography". We included original articles evaluating the performance of vaginal ultrasound in detecting acute PID. Seven articles were selected, including between 18 and 77 patients each. The golden standard used was laparoscopy/endometrial biopsy in six studies and mostly clinical evaluation in one. "Thick tubal walls" proved to be a specific and sensitive ultrasound sign of acute PID, provided that the walls of the tubes can be evaluated, i.e., when fluid is present in the tubal lumen (100% sensitivity). The cogwheel sign is also a specific sign of PID (95-99% specificity), but it seems to be less sensitive (0-86% sensitivity). Bilateral adnexal masses appearing either as small solid masses or as cystic masses with thick walls and possibly manifesting the cogwheel sign also seems to be a reasonably reliable sign (82% sensitivity, 83%specificity). Doppler results overlap too much between women with and without acute PID for them to be useful in the diagnosis of acute PID, even though acutely inflamed tubes are richly vascularized at color Doppler. Even though the results of our review suggest that transvaginal ultrasound has limited ability to diagnose acute PID, it is likely to be helpful when managing women with symptoms of acute PID, because in some cases the typical ultrasound signs of acute PID can be detected.

Factors that predict poor clinical course among patients hospitalized with pelvic inflammatory disease

The aim of this study was to identify factors that can predict clinical course among patients hospitalized with pelvic inflammatory disease (PID). Ninety-three patients who needed hospitalization with a diagnosis of PID were retrospectively studied. Patients who were discharged within 7 days by conservative treatment were defined as favorable course cases (n = 44). Patients who needed more than 7 days of hospitalization and/or surgery were defined as poor course cases (n = 49). Twenty variables were evaluated by univariate and logistic regression analysis: age, history of pregnancy/delivery, gynecological open/laparoscopic surgery, PID, oral contraceptives/intrauterine device use and intrauterine operation before onset, body temperature, signs of peritoneal irritation, vomiting/diarrhea, abnormal vaginal discharge, endometriosis/fibroid/adenomyosis/any cystic lesion detected by ultrasonography, white blood cell counts/C-reactive protein (CRP) levels . The cut-off value was calculated by receiver-operator curve (ROC) analysis. Factors associated with poor clinical course were advanced age (P < 0.01), history of gynecological open surgery (P < 0.05), any cystic lesion detected by ultrasonography (P < 0.05) and high CRP levels (P < 0.05). High CRP levels and intrauterine operation before onset were independently associated with poor clinical course. The cut-off value for CRP was 4.4 mg/dL. This study identified variables that can predict poor clinical course of PID. These results can assist gynecologists with identifying patients at risk and optimizing the choice of management.

National Trends in Pelvic Inflammatory Disease Among Adolescents in the Emergency Department

In 2002, the Centers for Disease Control and Prevention (CDC) broadened the pelvic inflammatory disease (PID) diagnostic criteria to increase detection and prevent serious sequelae of untreated PID. The impact of this change on PID detection is unknown. Our objectives were to estimate trends in PID diagnosis among adolescent emergency department (ED) patients before and after the revised CDC definition and to identify factors associated with PID diagnoses. We performed a retrospective repeated cross-sectional study using the National Hospital Ambulatory Medical Care Survey from 2000 to 2009 of ED visits by 14- to 21-year-old females. We calculated national estimates of PID rates and performed multivariable logistic regression analyses and tests of trends. During 2000-2009, of the 77 million female adolescent ED visits, there were an estimated 704,882 (95% confidence interval [CI], 571,807-837,957) cases of PID. After the revised criteria, PID diagnosis declined from 5.4 cases per 1,000 United States adolescent females to 3.9 cases per 1,000 (p = .03). In a multivariable model, age ≥17 years (odds ratio, 2.14; 95% CI, 1.25-3.64) and black race (odds ratio, 2.04; 95% CI, 1.36-3.07) were associated with PID diagnosis. Despite broadened CDC diagnostic criteria, PID diagnoses did not increase over time. This raises concern about awareness and incorporation of the new guidelines into clinical practice.

Pelvic Inflammatory Disease in the Adolescent

Pelvic inflammatory disease (PID) is a common clinical syndrome with highest rates in adolescents, but no studies have singularly focused on this population in relationship to established guidelines for diagnosis and treatment. The study objective was to assess knowledge of diagnosis and treatment criteria for PID within an adolescent population and to compare factors associated with adherence to Centers for Disease Control and Prevention guidelines in outpatient settings. Data were collected as part of a retrospective chart review of evaluation, diagnosis, and treatment of sexually transmitted infections in adolescent women in an outpatient setting. Participant charts were eligible for review if they were 12 to 21 years of age and were given an International Classification of Diseases, Ninth Revision/chart diagnosis of PID. Two primary outcome variables were utilized: meeting PID diagnosis guidelines (no/yes) and correct treatment for subject meeting criteria with guidelines (no/yes). The study controlled for race, age, medical venue, and current/past infection with gonorrhea/chlamydia. Subjects (n = 150) were examined for the primary outcome variables; 78% (117/150) met at least 1 criterion for PID diagnosis. Nearly 75% (111/150) had cervical motion tenderness, 34% (51/150) adnexal tenderness, and 5% (7/150) had uterine tenderness; nearly 11% (16/150) were positive for all 3 criteria. Symptoms associated with PID were compared for subjects meeting diagnosis criteria versus subjects not meeting diagnosis criteria: abdominal pain and vomiting were significantly associated with PID diagnosis at P < 0.05. Our findings show that PID diagnosis/treatment often does not follow guidelines in the adolescent population. Pelvic inflammatory disease and cervicitis appear to be confused by providers in the diagnosis process, and educational tools may be necessary to increase the knowledge base of practitioners in regard to PID.

Pitfalls of Research Linking the Intrauterine Device to Pelvic Inflammatory Disease

Correctly diagnosing pelvic inflammatory disease (PID) using noninvasive clinical criteria remains challenging. Current guidelines for initiating treatment, based on minimal criteria (sensitive but not specific), are justified for public health purposes but inadequate and misleading for scientific purposes. Previous research on the link between the intrauterine device (IUD) and PID was controversial and subject to many limitations. Even today, these limitations still exist and include uncertainty of the PID diagnosis, unfair contraceptive comparisons, selection and diagnostic bias, and confounding. For example, IUD users are on heightened alert for PID relative to users of other methods. In addition, IUD users with pelvic pain may be more likely to seek physician consultation and consequently receive a PID diagnosis (true-positive or false-positive). Confounding factors such as higher coital frequency, multiple sexual partners, and low condom use may explain any finding that shows a higher PID rate among IUD users compared with other contraceptive users. Good evidence on how or whether the IUD changes the etiology of PID is lacking. In the past 10 years, use of the intrauterine device in the United States has increased markedly. Thus today, researchers may now have sufficient population-level exposure (IUD use) and disease (PID) to search for a connection and repeat past mistakes. Any new findings using observational research should be interpreted with caution. More rigorous research designs may not be pragmatic or feasible.