Nongonococcal Pelvic Inflammatory Disease Research Articles

P126 The 2014/15 european collaborative clinical group (ECCG) service evaluation on the management of pelvic inflammatory disease

<h3>Background</h3> Pelvic Inflammatory Disease (PID) describes a broad spectrum of disease primarily diagnosed clinically, with signs and symptoms lacking both specificity and sensitivity. Mycoplasma genitalium (MG) is being increasingly implicated in cases of non-chlamydial non-gonococcal PID. The core principle of the management of PID remains to maintain a low threshold for diagnosis and treatment to prevent long-term sequelae. <h3>Aim</h3> To evaluate the current management of PID amongst sexual health physicians across Europe against the current European guidelines. <h3>Methods</h3> A clinical scenario based questionnaire was developed by a panel of European experts on PID, and this was disseminated to a group of 120 sexual health physicians across 38 countries who are members of the European Collaborative Clinical Group (ECCG) – a network of sexual health specialists who conduct questionnaire based research across the European region. <h3>Results</h3> Provisional results demonstrate variation in practice across Europe and this is most marked in routine testing for and treatment of MG-associated PID, factors influencing the choice of antibiotic therapy, and action taken when an intrauterine device or system is <i>in situ</i>. Full results will be available by the conference. <h3>Conclusion</h3> The management of PID varies across Europe and is not always in line with current European guidelines. There is a need for ongoing Europe wide education to ensure that patients are receiving evidence based care. Furthermore, there are issues in clinical practice which are currently not covered by the European guidelines and these need to be reviewed to provide physicians with appropriate guidance.

A comparison of treatment outcomes for moxifloxacin versus ofloxacin/metronidazole for first-line treatment of uncomplicated non-gonococcal pelvic inflammatory disease

Large randomized controlled trials support the efficacy of moxifloxacin for the treatment of uncomplicated pelvic inflammatory disease (PID). This study compares the clinical outcome and tolerability of treatment with moxifloxacin 400 mg once a day or ofloxacin 400 mg plus metronidazole 400 mg both twice daily in patients diagnosed with PID. A retrospective case-notes review was performed on patients diagnosed clinically with PID before and after local guidelines were changed to recommend moxifloxacin as first-line treatment for uncomplicated PID. Before the guidelines changed, 114/134 (85%) patients received the recommended first-line therapy versus 206/257 (80%) after the change, P = 0.3. There was no difference in the clinical outcomes between the two groups; significant improvement/resolved 77% versus 70%; marginal improvement 3% versus 11%; no change/worse 20% versus 18%, P = 0.14. Moxifloxacin is confirmed to be an effective alternative to ofloxacin/metronidazole for the treatment of PID in a large urban genitourinary clinic setting.

Infection of Ureaplasma urealyticum in the group of full-term infants

There were 50 patients with acute epididymitis who were evaluated prospectively by history, examination and microbiologic studies, including cultures for aerobes, anaerobes, Neisseria gonorrhoeae, Chlamydia trachomatis and Ureaplasma urealyticum. Escherichia coli was the predominant pathogen isolated from the urine of men more than 35 years old, while Chlamydia trachomatis and Neisseria gonorrhoeae were the predominant pathogens isolated from the urethra of men less than 35 years old. The etiologic role of Escherichia coli and Chlamydia trachomatis was confirmed by isolation from epididymal aspirates from a high proportion of men with positive urine or urethral cultures for these agents. Chlamydia trachomatis epididymitis accounted for two-thirds of idiopathic epididymitis in young men and often was associated with oligospermia. Of 9 female sexual partners of men with Chlamydia trachomatis infection 6 had antibody to Chlamydia trachomatis, of whom 2 had positive cervical cultures for this organism and 2 others had non-gonococcal pelvic inflammatory disease. Antibiotic therapy with tetracycline was effective for the treatment of men with Chlamydia trachomatis epididymitis and should be offered to the female sex partners

Evaluation of the POCkit™ HSV2 serology test at point-of-care

There were 50 patients with acute epididymitis who were evaluated prospectively by history, examination and microbiologic studies, including cultures for aerobes, anaerobes, Neisseria gonorrhoeae, Chlamydia trachomatis and Ureaplasma urealyticum. Escherichia coli was the predominant pathogen isolated from the urine of men more than 35 years old, while Chlamydia trachomatis and Neisseria gonorrhoeae were the predominant pathogens isolated from the urethra of men less than 35 years old. The etiologic role of Escherichia coli and Chlamydia trachomatis was confirmed by isolation from epididymal aspirates from a high proportion of men with positive urine or urethral cultures for these agents. Chlamydia trachomatis epididymitis accounted for two-thirds of idiopathic epididymitis in young men and often was associated with oligospermia. Of 9 female sexual partners of men with Chlamydia trachomatis infection 6 had antibody to Chlamydia trachomatis, of whom 2 had positive cervical cultures for this organism and 2 others had non-gonococcal pelvic inflammatory disease. Antibiotic therapy with tetracycline was effective for the treatment of men with Chlamydia trachomatis epididymitis and should be offered to the female sex partners

Risk factors for Chlamydia trachomatis pelvic inflammatory disease among sex workers in Nairobi, Kenya.

Among 302 female sex workers in Nairobi, Kenya, who were followed for 17.6 +/- 11.1 months, 146 had one or more infections with Chlamydia trachomatis; 102 had uncomplicated cervical infection only, 23 had C. trachomatis pelvic inflammatory disease (PID), and 21 had combined C. trachomatis and Neisseria gonorrhoeae PID. As determined by multivariate logistic regression analysis, risk factors for C. trachomatis PID included repeated C. trachomatis infection (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.3-2.4; P = .0004), antibody to C. trachomatis heat-shock protein 60 (OR, 3.9; CI, 1.04-14.5; P = .04), oral contraceptive use (OR, 0.28; 95% CI, 0.08-0.99; P = .048), and number of episodes of nongonococcal nonchlamydial PID (OR, 1.7; 95% CI, 1.1-2.7; P = .02). Among human immunodeficiency virus (HIV)-seropositive women, a CD4 lymphocyte count of <400/mm3 was an additional independent risk factor for C. trachomatis PID (OR, 21.7; 95% CI, 1.2-383; P = .036); among HLA-typed women, HLA-A31 was independently associated with C. trachomatis PID (OR, 5.6; 95% CI, 1.1-29.4; P = .043). The results suggest an immune-mediated pathogenesis for C. trachomatis PID.

Pelvic inflammatory disease.

This article reviews current knowledge on the diagnosis pathogenesis epidemiology treatment and prognosis of pelvic inflammatory disease (PID). Since PID has important implications for future health and fertility its diagnosis and management are of utmost importance. A recent study of the accuracy of clinical diagnosis of PID indicated that even when as many as 7 reliable symptoms and signs were present there was still possibility for diagnostic error. This has led some to advocate diagnostic laparoscopy. In older women IUD users and women who have recently delivered or undergone pelvic surgery endogenous organisms are more likely to be the initial infecting agents. Treatment of PID should be begun before the results of microbiological investigations are available and should cover a wide spectrum of organisms. The authors preference is a combination of penicillin or ampicillin in high dose gentamicin and rectal metronidazole. Follow up treatment with tetracycline or erythromycin is needed to eradicate chlamydial infection. The author also prefers to remove an IUD in place once antibiotic cover has been established. The longterm prognosis in such cases is not good especially after nongonococcal PID. 25% of a group of 415 PID patients followed for 10 years had reinfections and 18% suffered chronic pelvic pain. 21% were involuntarily infertile and tubal occlusion rates rose from 13% after 1 attack to 75% in those who had been infected 3 or more times. When PID patients did become pregnant ectopic pregnancy was 6 times more common than in a group of matched controls.

Treating pelvic inflammatory disease with doxycycline and metronidazole or penicillin and metronidazole.

The best way of treating pelvic inflammatory disease (PID) is not known. The clinical response to two treatment regimens (penicillin plus metronidazole v doxycycline plus metronidazole) was studied in 33 patients with PID confirmed by laparoscopy and endometrial biopsy. The overall failure rate, according to the criteria used in this study was five of 11 (45%) women with chlamydial PID, none of six women with gonococcal PID, all of four women with chlamydial gonococcal PID, and three (25%) of 12 women with non-chlamydial non-gonococcal PID. The failure rate with penicillin plus metronidazole treatment was unacceptably high (53%), and significantly higher than that with doxycycline plus metronidazole (19%) (p = 0.038). In most cases the microbiological and histopathological evaluations identified a probable explanation for the poor response to the treatment regimen used.

Comparison of the clinical and epidemiologic characteristics of gonococcal and nongonococcal pelvic inflammatory disease seen in a clinic for sexually transmitted diseases, 1978-1979.

Despite the magnitude of the clinical and economic impact of pelvic inflammatory disease (PID), little is known about its outpatient presentation. We compared retrospectively the clinical and epidemiologic characteristics of 70 women with gonococcal PID, 44 women with nongonococcal PID, and 8,576 control women without PID seen in a clinic for sexually transmitted diseases. Gonococcal PID was associated with black race (P less than .002) and a shorter period of abdominal pain (P less than .02). Nongonococcal PID was associated with white race (P less than .005) and a history of previous gonococcal infection (P less than .02). There were no significant differences between groups in age, parity, number of sexual partners, contraceptive use, or febrility. PID seen in women attending our outpatient clinic is often mild, and the diagnosis uncertain. We found few reliable indicators to aid in the clinical diagnosis or to distinguish etiology. More studies are needed to improve the outpatient management of PID and limit its impact.

Oral Contraceptives, Chlamydia trachomatis Infection, and Pelvic Inflammatory Disease

Management of pelvic inflammatory disease (PID) and decisions about contraception are being influenced by reports that oral contraceptives decrease the risk of PID. To evaluate the validity of this association, we have examined published epidemiologic evidence and reviewed relevant information from other disciplines. Current information does not permit the generalization that oral contraceptives protect against all forms of PID. Most studies conducted (1) have been limited to hospitalized women, who represent less than 25% of all PID cases and are likely to have relatively severe forms of the disease, and (2) have failed to distinguish between gonococcal and nongonococcal PID. While oral contraceptives may provide some protection against gonococcal PID, no basis exists for assuming similar protection is provided against chlamydial PID. In fact, epidemiologic and biologic evidence suggests that infection with Chlamydia trachomatis, the leading cause of nongonococcal PID, is enhanced by oral contraceptives. We judge the conclusion that oral contraceptives protect against all PID to be premature, and urge caution in its application in health policy and clinical decisions.

Antibodies to Chlamydia trachomatis, Mycoplasma hominis, and Neisseria gonorrhoeae in Sera from Patients with Acute Salpingitis

Although there are diverse opinions on the proportion of acute salpingitis caused by Neisseria gonorrhoeae, most workers agree that other agents can be responsible for this condition. The authors have shown previously that Chlamydia trachomatis and Mycoplasma homonis are agents that may cause nongonococcal pelvic inflammatory disease. In the present study, they tested paired sera from 60 consecutive patients with acute salpingitis for antibodies to C. trachomatis by an indirect immuno-fluorescence test, and for antibodies to M. hominis and N. gonorrhoeae by indirect hemagglutination tests. Sera from 50 pregnant women attending consecutively from the same hospital catchment area served as controls. Antibodies (lgG or lgM or both) to C. trachomatis were detected in 80 per cent of the patients, and antibodies to M. homonis and N. gonorrhoeae were found in 40 per cent and 18 per cent, respectively. lgM antibodies to C. trachomatis occurred in 12, and lgG antibodies to the same organism occurred in all 48 seropositive patients. A significant change in antibody titre to C. trachomatis occurred in 40 per cent of the patients (21 with lgG, one with lgM, and two with both antibodies), to M. homonis in 12 per cent, and to N. gonorrhoeae in 5 per cent. The predictive values for a positive and a negative microimmunofluorescence test result were 44 per cent and 83 per cent, respectively; those for the indirect hemagglutination gonococcal pilar antibody test were 36 and 100 per cent, respectively. These calculations were based on the assumption that the diagnosis of a current infection was equivalent to a positive culture result for the organism. None of the 12 patients with lgM antibodies to C. trachomatis was culture positive for chlamydia. Evidence of a current infection (culture positive or significant change of antibody titer or both) with C. trachomatis and N. gonorrhoeae occurred in 35 (58 per cent) and five (8 per cent), respectively. Of the 23 patients with positive cultures for chiamydia, 17, 5, and 1 had titres of less than 64, from 128 to 156, and greater than 512, respectively. Ten had a significant rise in the titre of antichla-mydial lgG antibodies. The four patients who harbored gonococci were in the group of 11 patients who had indirect hemagglutination pilar antibodies to N. gonorrhoeae. Two of the three patients with a significant rise in titre harbored gonococci. There was a correlation between the severity of the tubal changes and the results of the microimmunofluorescence tests (P < 0.005) and between the duration of pelvic pain before attendance and the results of serological tests (P < 0.009). Four (7 per cent) of the 60 patients had a significant rise in antibody titres to both C. trachomatis and M. hominis. The three patients with a significant rise in the titre of indirect hemagglutination pilar antibodies had no evidence of current infection with chlamydia or mycoplasmas. Antibodies to C. trachomatis, M. hominis, and N. gonorrhoeae were demonstrated in 8, 8, and 6 per cent, respectively, of the sera from the control group of pregnant women. The study showed that acute salpingitis in Lund is associated with a current genital chlamydial infection in at least 40 per cent of the patients, whereas gonococcal infections at present occur in only a small proportion of all cases of salpingitis (8 per cent). Acute infections with M. hominis could be detected in 10 to 15 per cent of the patients with acute salpingitis in the area.

Nongonococcal pelvic inflammatory disease.

Nongonococcal PID remains a major concern in gynecology and an important public health problem. Although debate continues as to the etiologic role of nongonococcal organisms in acute PID, anaerobic and aerobic bacteria, C. trachomatis, and mycoplasmas have all been implicated. Actinomycotic PID is uniquely related to IUD use. The optimal treatment for nongonococcal PID is unknown, but tetracycline and its derivatives are effective against a broad spectrum of nongonococcal organisms. Abscesses and infertility, in particular, are serious complications of nongonococcal PID. While evolving knowledge about the polymicrobial etiology of acute PID has challenged traditional concepts, continued research should clarify the epidemiology, treatment, and prevention of this important disease.

Cefotaxime treatment of pelvic inflammatory disease.

We studied cefotaxime in the treatment of gonococcal and nongonococcal pelvic inflammatory disease. Cefotaxime was uniformly effective against gonococcal pelvic inflammatory disease. However, 4 of 11 patients with nongonococcal pelvic inflammatory disease had a suboptimal response.

The Genital Mycoplasmas

Current concepts of the role of the mycoplasmas M. hominis and U. urealyticum in diseases of the genital tract in men and women are outlined. Both mycoplasmas have been isolated more often from black men and women than from whites even when sexual experience is controlled. Recent evidence suggests U. urealyticum is a cause of nonchlamydial nongonococcal urethritis. However more cases of this disorder would be expected given the frequency with which sexually active men are exposed to ureaplasmas. Similarly these organisms are frequently recovered from men who do not develop urethritis. 3 hypotheses have been advanced to explain this puzzle: 1) only certain groups of U. urealyticum have the potential to cause disease; 2) the microorganism is of low invasiveness causing cliniclally recognizable infection in only a small proportion of exposed men; and 3) urethritis occurs only when a person is 1st exposed to U. urealyticum. A possible causal association between M. hominis and chronic prostatitis is also under investigation. The mycoplasmas are not considered to be an important cause of epididymitis or Reiters disease. In women M. hominis is often isolated in association with other vaginal pathogens and could play a role in nonspecific vaginitis; however its relative importance is unclear. Mycoplasmas are not considered to be an important cause of abscesses of Bartholins gland. However data suggest they may have a primary pathogenic role in some cases of acute pelvic inflammatory disease (PID). Clarification of the contribution of M. hominis and U. urealyticum to both gonococcal and nongonococcal PID will require studies in which laparoscopically obtained specimens from inflamed fallopian tubes are examined for N. gonorrhoeae C. trachomatis aerobic and anaerobic bacteria and genital mycoplasmas. Other studies suggest that M. hominis causes some cases of fever after abortion as well as postpartum fever. Again further studies are needed to define the contribution of M. hominis to contemporary postpartum fever in relation to that of other microorganisms.

Etiology, Manifestations and Therapy of Acute Epididymitis: Prospective Study of 50 Cases

There were 50 patients with acute epididymitis who were evaluated prospectively by history, examination and microbiologic studies, including cultures for aerobes, anaerobes, Neisseria gonorrhoeae, Chlamydia trachomatis and Ureaplasma urealyticum. Escherichia coli was the predominant pathogen isolated from the urine of men more than 35 years old, while Chlamydia trachomatis and Neisseria gonorrhoeae were the predominant pathogens isolated from the urethra of men less than 35 years old. The etiologic role of Escherichia coli and Chlamydia trachomatis was confirmed by isolation from epididymal aspirates from a high proportion of men with positive urine or urethral cultures for these agents. Chlamydia trachomatis epididymitis accounted for two-thirds of idiopathic epididymitis in young men and often was associated with oligospermia. Of 9 female sexual partners of men with Chlamydia trachomatis infection 6 had antibody to Chlamydia trachomatis, of whom 2 had positive cervical cultures for this organism and 2 others had non-gonococcal pelvic inflammatory disease. Antibiotic therapy with tetracycline was effective for the treatment of men with Chlamydia trachomatis epididymitis and should be offered to the female sex partners

Management of gonococcal pelvic inflammatory disease.

Information that has become available since 1974 on the management of pelvic infections unrelated to abortions, the puerperium, or pelvic surgery, with an emphasis on those associated with Neisseria gonorrhoeae are summaried. Attention is directed to both diagnosis (clinical, bacteriologic) and therapy (hospitalized patients, outpatients, indications for hospitalization, and IUDs). Most investigators classify acute pelvic inflammatory disease (PID) as gonococcal or nongonococcal on the basis of the presence or absence of N. gonorrhoeae in cervical specimens. As compared with patients who have nongonococcal pelvic inflammatory disease, patients who have gonococcal disease are often younger, more likely to have elevated temperatures, and more often experience pain in the first 10 days of the menstrual cycle. It is not possible to differentiate gonogoccal from nongonococcal pelvic inflammatory disease without the aid of laboratory tests. N. gonorrhoeae can be isolated from the cervix in 20-80% of acute PID. Much of the variation can be explained by differences in the prevalences of gonorrhea in different populations. In populations with high prevalence of gonorrhea, most cases of acute PID are associated with gonorrheal infection. Where gonorrhea is less common, N. gonorrhoeae is isolated from the cervix in fewer than half of cases of acute PID. Neisseria gonorrhoeae can be demonstrated in the fallopian tube or peritoneal cavity of 8-70% of patients with PID whose cervical cultures yield N. gonorrhoeae. When N. gonorrhoeae is isolated from the lower genital tract of a patient who has acute pelvic inflammatory disease, causal significance is appropriately ascribed to that organism. The use of gram staining of cervical specimens to diagnose uncomplicated gonorrhea in women has been discouraged due to low sensitivity and specificity compared with cultures on selective medium. Comparative evaluation of studies of therapy of acute pelvic inflammatory disease is hampered by differences in criteria for diagnosis of cases, in indications for hospitalization and surgical treatment, in durations of therapy and follow-up, and in criteria for cure. The information available is insufficient to justify recommending a change in the 1974 schedules for therapy of hospitalized patients. Results of 2 studies of treatment of outpatients with PID are summarized in a table. Cunningham et al. reported satisfactory bacteriologic and clinical cure rates for gonococcal PID after use of the currently recommended treatment schedules. McCormack et al. obtained satisfactory results with a 5-day course of spectinomycin HCI administered to a small number of patients. Sweet recommended that hospitalization be considered for all patients with acute PID, as is the practice of many facilities in Sweden. It is now clearly documented that users of IUDs have a 3-9 fold greater risk of developing PID as compared with nonusers. All patients treated for acute PID should be followed closely to monitor their responses to therapy. Controlled therapeutic trials of acute PID should ensure similarity of case definition and identification of "cure."

Acute epididymitis: etiology and therapy.

Fifty patients with acute epididymitis were evaluated prospectively by history, examination, and microbiologic studies, including cultures for aerobes, anaerobes, N. gonorrhoeae, Chlamydia trachomatis, and Ureaplasma urealyticum. E. Coli was the predominant pathogen isolated from the urine of men over 35 years old and C. trachomatis and N. gonnorrheae were the predominant pathogens isolated from the urethra of men under 35. The etiologic role of E. Coli and C. trachomatis was confirmed by isolation from epididymal aspirates from a high proportion of men with positive urine of urethral cultures for these agents. C. trachomatis epididymitis accounted for two thirds of "idiopathic epididymitis" in men, and was often associated with oligozoospermia. Of nine female sexual partners of men with C. trachomatis infection, six had antibody to C. trachomatis, of whom two had positive cervical cultures for this organism, and the others had nongonococcal pelvic inflammatory disease. Antibiotic therapy with tetracycline was effective for the treatment of men with C. trachomatis epididymitis, and should be offered to their female sex partner.

Quantitative Determination of the Serum Antibody Response to the Capsular Polysaccharide of Bacteroides fragilis subspecies fragilis in Women with Pelvic Inflammatory Disease

The antibody response to the capsular polysaccharide of Bacteroides fragilis subspecies fragilis in women with acute pelvic inflammatory disease was quantitated using a sensitive radioactive antigen-binding assay. Antibody detected by this technique correlated highly with antibody measured by quantitative precipitin analysis (r = 0.99). Paired acute- and convalescent-phase sera obtained from women from whom B. fragilis subspecies fragilis was isolated by culdocentesis showed significantly greater changes in antibody concentration than corresponding sera obtained from women with gonococcal or nongonococcal pelvic inflammatory disease when B. fragilis subspecies fragilis was not isolated from the cul-de-sac. These data indicate that the steady state of immunity to this capsular antigen is perturbed in patients with acute nongonococcal pelvic inflammatory disease from whom this organism can be cultured. This finding may indicate that B. fragilis can play a significant role in acute pelvic inflammatory disease and can be involved early in the infectious process.

Acute Pelvic Inflammatory Disease

We studied 41 women with acute gonococcal pelvic inflammatory disease and 42 women with acute nongonococcal pelvic inflammatory disease. Women with gonococcal pelvic inflammatory disease were more likely to have become ill during the first 10 days of their menstrual cycle (P < 0.05), presented themselves for treatment sooner (P < 0.05), and were more severely ill than patients with nongonococcal pelvic inflammatory disease (P < 0.05). Patients were treated with aqueous procaine penicillin G or with spectinomycin hydro-chloride for five days. Most of the patients with gonococcal disease responded to treatment. Neither drug, in the dosage employed in this study, was highly effective in the treatment of acute nongonococcal pelvic inflammatory disease. In all, 10 of 21 women with nongonococcal pelvic inflammatory disease and only one of 19 women with gonococcal pelvic inflammatory disease required retreatment for pelvic inflammatory disease within 28 days (P < 0.05). Reexamination an average of 17 months following treatment showed that women who had been treated for nongonococcal pelvic inflammatory disease were more likely to develop recurrent pelvic inflammatory disease if the episode of pelvic inflammatory disease treated in the study was not their first. Women treated for nongonococcal pelvic inflammatory disease were also less likely to become pregnant (P < 0.05). These data, which show that gonococcal and nongonococcal pelvic inflammatory disease differ in initial clinical severity, response to treatment, and long-term complications, support the concept that gonococcal pelvic inflammatory disease and nongonococcal pelvic inflammatory disease are separate clinical entities.

Gonorrhea Screening in Male Consorts of Women With Pelvic Infection

Neisseria gonorrhoeae was isolated from 39% of male contacts of women with acute gonococcal pelvic inflammatory disease (PID); 22% of these men were asymptomatic. More than half of those women with gonococcal PID had at least one male sexual consort with gonorrhea. Neisseria gonorrhoeae was isolated from 15% of male contacts of women with nongonococcal PID; 30% were asymptomatic. Since a substantial number of male contacts of women with acute PID will have cultures positive for N gonorrhoeae and are asymptomatic, all male sexual consorts should be examined and have cultures grown for gonorrhea.

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 < 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 < 0.025). Among women with nongonococcal PID, and adnexal mass ≥ 6 cm. was noted in 14 (40 per cent) of 35 IUD users and in only 12 (15 per cent) of 78 nonusers (p < 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.