Genital actinomycosis and intrauterine contraceptive devices. Cytopathologic diagnosis and clinical significance.

This study from a community hospital documents the relatively frequent occurrence of Actinomyces in 36 women diagnosed by Papanicolaou stained cervicovaginal smears. Actinomyces was identified exclusively in patients wearing an intrauterine or vaginal foreign body (intrauterine devices and pessaries). By using fluorescein isothiocyanate labeled antiserum, the organisms were shown to be Actinomyces israelii in eight randomly selected smears. In five cases Actinomyces was demonstrated in tissues obtained by endocervical and endometrial curettage. Anaerobic microbiologic studies performed in 11 of the 36 cases showed a relatively high rate of recovery of Actinomyces (36.3 per cent) with a yield of four positive cultures. In two cases the isolated organisms were shown to be Actinomyces israelii. In the remaining two cases the exact species of Actinomyces has remained uncertain. Of the 36 patients with smear evidence of Actinomyces, nine (25 per cent) had pelvic inflammatory disease, a rate that appears to be much higher than the already high rate among all intrauterine device users. This observation underscores the importance and clinical significance of the finding of Actinomyces in the vaginal smears of intrauterine device users. Papanicolaou stained cervicovaginal smears provide a relatively easy, inexpensive, fast, and highly specific method for the morphologic diagnosis of Actinomyces and allows us to recognize at a relatively early stage a group of patients who are potentially at risk for the development of pelvic inflammatory disease and its associated more severe complications. The hope is that prompt identification of Actinomyces in cervicovaginal smears can help to prevent the more serious infectious complications in intrauterine device users.

PIP: Occurrence of Actinomyces in 36 women (from September 1976-May 1977) diagnosed by Papinocolaou (Pap)-stained cervical smears (total of 9191 smears) is characterized as "relatively frequent," occurring exclusively in those women wearing an IUD or foreign vaginal body (pessaries). Fluorescein isothiocyante labeled antiserum was used to identify Actinomyces israelii in 8 randomly selected smears. In 5 cases, Actinomyces was demonstrated in tissues obtained by endocervical and endometrial curettage. The recovery rate of Actinomyces in anaerobic microbiological cultures was 36.3%, with a yield of 4 positive cultures. Of the 36 patients with smear evidence of the organism, 9 (25%) had pelvic inflammatory diseases (PID); this rate appears to be much higher than the high rate already established for IUD wearers. Pap-stained smears, easily used in a community hospital, provide an easy, inexpensive, fast and highly specific method for morphologically diagnosing Actinomyces, and its use is recommended to recognize at a relatively early stage a group of patients who are potentially at risk for the development of PID.

IUDs, inflammation, and infection: assessment after two decades of IUD use.

PIP: In the 1950s social and technological changes allowed experimental use of an inert plastic IUD which was successful and regarded as safe. The devices were pliable, chemically inert, sterilizable, disposable, and equipped with a small inserter so that cervical dilation was not needed for insertion. But many IUDs were withdrawn because they were found to cause endometritis and provide poor protection against pregnancy. In the 1970s there were cases of serious inflammatory and infectious diseases with pelvic inflammatory disease (PID) the most common. The Dalkon Shield has been associated with midtrimester septic abortions and with unilateral actinomycotic tube-ovarian abscesses and there is evidence to support a chemically caused IUD-related endometritis in the moderate inflammation associated with IUDs containing copper and with the Majzlin spring. The most common factor among IUD users with Actinomycetales infection is not the type of IUD but the duration of use; almost 85% of cases were in women who had worn IUDs over 3 years. Also the likelihood of an ectopic pregnancy is almost 3 times greater for longterm IUD users. It is hypothesized that with time the IUD is capable of inducing changes that can lead to infection and that changes can occur to the IUD itself. A surface coating on the IUD and the tail has been found which is composed of mucoid and cellular elements which consist of an inflammatory response; the IUD then becomes recognized as a foreign body to the host and may contribute to the development of PID. Other problems such as perforation, cramping, bleeding, and unwanted pregnancy may be at least indirectly related to IUD surface alterations. It is now agreed that all IUD-associated inflammatory and infectious disease can no longer be considered gonorrheal type PID and that the biodegradation of the nylon-6 tail of the Dalkon shield may also be a factor in PID. Some recommendations are to: 1) change IUDs every 2 years, 2) counsel women on IUD complications and examine IUDs upon removal, and 3) bring IUD technology up to date to develop an IUD that is thoroughly safe and effective.^ieng

The intrauterine device and pelvic inflammatory disease: the Women's Health Study reanalyzed.

The Women's Health Study (WHS) was a large, widely accepted and influential case-control study of the relationship between the use of intrauterine contraceptive devices (IUDs) and pelvic inflammatory disease (PID). The data were collected at 16 hospitals in 9 cities across the U.S.A. from October 1976 through August 1978. The first paper on this research was published in 1981 and concluded that IUDs increase the risk of PID. The report cited an estimated RR (relative risk) of PID for current IUD users vs nonIUD users of 1.6 with a 95% confidence interval of (1.4, 1.9). However, careful examination of the report reveals that the data support conclusions antithetical to those at which the author arrived. When the second report on the WHS was published in 1983, it was anticipated that many of the shortcomings of the first report would be corrected, but they were not. In 1983 we undertook a complete reanalysis of the same WHS data using more appropriate criteria and the results were compared to the first two published reports. The reanalysis revealed an RR of 1.02 (0.86, 1.21) for current IUD users compared to noncontraceptors. The conclusion of the WHS should have been that IUDs do not increase the risk of PID.

Contraception with intrauterine devices.

PIP: A review of the history of contraception with intrauterine devices, characteristics of present devices, and directions of current research is presented. The serious need for population control is not yet being met by today's inconvenient, ineffective, or unsafe methods. Intrauterine devices have been best for international family planning programs because they are cheap, easily installed, and provide continuous protection. There are many different models that have been and are being used, with different effectiveness and complication rates. The most commonly used today is the Lippes Loop, with a pregnancy rate of 2.8/100 years of woman use and an expulsion rate of 10.4. Most of these failures occur in the first few months of use, after which these rates are greatly reduced. The removal rate because of bleeding or pain for the Lippes device is 14.0. Other devices commonly used have pregnancy rates ranging 1.3-4.7, expulsion rates of 2.6-25.8, and removal rates of 13.5-22.1. Expulsion is directly related to the size and design of the IUD and the age and parity of t,e recipient. It is important to match the size of the device used to the individual characteristics of the patient. Research is seeking a design that will implant itself in the endometrium to resist expulsion, but not too deeply so that it is covered. Removal for bleeding and pain remains the most frequent complication of the IUD, and it partly depends on the skill of the inserting physician and how well the patient is psychologically prepared for side effects in the first months of use. Pregnancy is the most significant IUD complication. The key to an effective IUD is an understanding of its antifertility mechanism, which has thus far eluded researchers. The IUD prevents implantation of the blastocyst in the uterine wall, which may be due to a foreign-body reaction in the endometrium. IUDs with copper cause a greater reaction than plastic devices and provide hope for a very effective device; particularly the T-shaped design, which resists expulsion. The most promising new IUD is the Dalkon Shield. It has small projections that imbed in the endometrium and a broad surface for contact with the uterine wall. In preliminary experiments the pregnancy rate with this device was 1.1, the expulsion rate 2.3, and the removal rate 2.0, much lower than that with any other device yet developed. It is concluded that IUDs such as the Dalkon Shield can provide safe contraception with high effectiveness.^ieng

Intrauterine device use and risk of tubal pregnancy: an Indonesian case-control study.

BACKGROUND: We assessed the risk of tubal pregnancy among women who (1) were currently using an intrauterine device (IUD) and (2) had discontinued IUD use while still sexually active and at risk of pregnancy using data from a multicentre case-control study of married women conducted in Indonesia. METHODS: Cases were 560 women diagnosed with histologically confirmed ectopic pregnancy from April 1989 to August 1990 at any one of 11 participating hospitals. Controls were 1120 non-pregnant women similar in age and place of residence to the cases. In-person interviews were conducted to collect information regarding current and past contraceptive use as well as other demographic and personal characteristics. RESULTS: Women currently using an IUD were considerably less likely than women not currently using contraception, but more likely than users of hormonal or surgical means of contraception, to develop a tubal pregnancy. Women who had discontinued using an IUD had a 70% subsequent increase in risk of tubal pregnancy (adjusted RR = 1.7, 95% Cl: 1.1-2.5) relative to women who had never used an IUD. This increase in risk was most pronounced in women who reported multiple episodes of IUD use and, to a lesser extent, in women with a long (> 3 year) duration of IUD use. CONCLUSIONS: The associations we observed are similar to those previously reported in studies conducted in developed countries. The results are of particular interest because this study was conducted in a location in which the Dalkon Shield IUD was never available, and among a population of married, gravid women for whom IUD use is generally considered most appropriate.

Management of incarcerated vaginal pessaries.

Uterine procidentia is relatively common among white multiparous women. The incidence increases with age in association with other predisposing factors. Conservative management of uterine prolapse is rare today, perhaps due to definitive results with surgical therapy and the high incidence of earlier hysterectomy. Still, physicians should become familiar with pessary use and its complications. Three conservatively managed cases of pessary incarceration are reported. Applications of estrogen cream improved the condition of the vagina, permitting removal of the incarcerated pessary a few day later. Careful instruction of patients and relatives about follow-up care can prevent such complications.

PIP: Uterine procidentia and pelvic-floor hernia are quite common among postmenopausal multiparous Caucasian women. Predisposing factors are age, obesity, childbirth trauma, neurologic disorders, and musculo-fascia weaknesses. Hysterectomy and pelvic floor repair constitute the definitive therapy for pelvic floor hernia and uterine prolapse, but vaginal pessaries made of rubber or plastic can also be of therapeutic value. Pessaries also facilitate preoperative healing of the vaginal or cervical ulcerations which are quite common in longstanding cases of uterine procidentia (third degree prolapse). Common complications of pessary use are vaginal irritation, allergic reactions, leukorrhea and bleeding. Hard pessaries have fewer associated complications. Proper fitting and continued post insertion care are necessary. Unless contraindicated, acid douches and or creams and estrogenic creams should be used with the pessaries. Pessaries should be removed every 6 weeks for cleansing; otherwise, ulceration, superimposed infections, and fistulas could develop. In cases of incarcerated pessaries, the use of estrogenic creams (which improve the condition of the vagina) will easily help remove the pessaries. 3 case reports are briefly discussed to illustrate the management of incarcerated pessaries in elderly women. The patients reported in these cases did not have follow-up care after insertion of the pessary, thus requiring intervention years later. Patients with bleeding problems despite normal cytologic findings should undergo fractional curettage later to rule out malignancy. Although incarcerated pessaries rarely occur, application of estrogenic creams will easily remove them.

Letter: Infection and the IUD.

PIP: In his paper entitled "Pelvic Actinomycosis Associated With an Intrauterine Device" appearing, in the May 1973 Obstetrics and Gynecology, Dr. Henderson states that "the incidence of ordinary pelvic infection with the intrauterine device varies from .5 to .9 per 100 women years..." One of the three references given is to an article of mine. Unfortunately, the figures cited by Dr. Henderson do not appear in my article. My findings in Atlanta, Georgia, suggested that the incidence of first episode pelvic inflammatory disease in a population of indigent women between 15 and 45 in 1965 was 1%. The comparable rate among indigent women wearing intrauterine devices was 7%. My findings tended to the conclusion that women wearing an IUD in this indigent population were at greater risk of contracting acute pelvic inflammatory disease than non-wearers, a conclusion which has not been conctradicted by other comparable studies, the opinion of the World Organization notwithstanding. I realize that this is not a major point in Dr. Henderson's presentation, but I wanted to set the record straight.^ieng

Uterine perforation by Lippes loop.

PIP: After a 32-year-old women was unable to locate a C Lippes Loop (inserted approximately 9 weeks postpartum) at any time during a four week period after insertion, the position of the device was shown by x-ray to be extrauterine. Removal of the IUD necessitated a colpotomy, resulting in bleeding which could not be controlled vaginally. Following laparotomy, grasping of the extremely friable uterus caused tearing of the Fallopian tubes from the uterus. A hysterectomy was performed. This case demonstrate the real, if rare, possibility of perforation of the uterus with the Lippes Loop.^ieng

Absence of bacteremia after insertion or removal of intrauterine devices.

A prospective study of the risk of bacteremia in 84 women having insertion and in 16 women having removal of intrauterine devices was performed. Bacteremia was not found in any of these 100 women at 1 to 3, 15, or 30 minutes after the procedure or in any of 57 women studied again 1.5 hours later. Because of the remote risk of bacteremia, the presence of congenital or valvular heart disease need not be an absolute contraindication to the use of an intrauterine device for contraception in an otherwise healthy young woman. Prophylactic antimicrobial therapy during insertion or removal of an intrauterine device appears to be unnecessary in the absence of evident pelvic infections. The risk of bacteremia during removal of an intrauterine device from an infected uterus cannot be determined from this study.

PIP: 100 healthy women who requested insertion (84) or removal (16) of an IUD were studied to determine the risk of bacteremia. Blood for culture was obtained before the procedure and 1-3 minutes, 15 and 30 minutes after the procedure in al 100 women and at 1.5 hours afterwards in 57. Blood cultures were incubated for 7 days sampled and stained by the Gram method and subcultured to chocolate agar for 48 hours. At 21 days samples were subcultured to blood agar, and to blood chocolate and MacConkey agars for 48 hours. Bacteria isolated from 3 women were thought to be skin contaminents. Results indicated that transient bacteremia during insertion or removal of an IUD is a rare event. In the presence of congenital or valvular heart disease it is unnecessary to consider these as absolute contraindications to an IUD. Prophylactic antimicrobial therapy during insertion or removal of an IUD is probably unnecessary.

Unilateral tubo-ovarian abscess and intrauterine contraceptive devices.

The association of unilateral tubo-ovarian abscess and the presence or use of an intrauterine contraceptive device (IUD) appears to be a definite clinical entity. Four cases of unilateral tubo-ovarian abscess in patients using the IUD are presented. Three patients had a Dalkon Shield IUD and one had a Lippes Loop. Two patients had unilateral salpingo-oophorectomy while the other 2 had total abdominal hysterectomy and bilateral salpingo-oophorectomy. The differential diagnosis, possible etiology, route and mode of infection, and management are discussed.

PIP: 4 cases of unilateral tuboovarian abscess in patients using an IUD are presented; 3 of the 4 patients had a Dalkon shield and 1 had a Lippes loop. These cases present the problem of diagnosis and treatment as the presence of pelvic mass in an IUD user may be due to an ectopic pregnancy, ovarian cyst, or a pelvic or tuboovarian abscess. Unruptured tuboovarian abscess requires conservative treatment with antibiotics initially and surgery if there is an unsatisfactory response. These patients display a high fever and purulent cervical discharge. An ascending infection is associated with IUD use and recent investigations implicate the tail, especially the compound variety. Trauma to the endometrium by the IUD may initiate the infection and the finlike projections of the IUD may cause further trauma. The connection of unilateral tubooovarian inflammatory mass with the IUD user should alert more clinicians to this possibility.

Removal of intrauterine contraceptive devices after uterine perforation.

PIP: Rates of perforation for different types of IUDs vary from 1 per 150 insertions with the bow to 1 per 2500 with the loop. Incidence of perforation varies with insertion technic. Not all perforations occur at the time of insertion but most do. These perforations may be partial or complete, with or without symptoms, and complications range from mild anxiety to life-threatening situations. With the older closed-loop devices intestinal strangulation was a threat. Partial perforations have been identified as sources of intestinal volvulus and septic abortions. With the increase use of IUDs and the increased frequency of perforations, a technic simpler than laparotomy was desired to remove intraperitoneal devices. Laparoscopy seems safer and is associated with fewer side effects than laparotomy. Before attempting removal, the patient is examined to determine if the string attached to the IUD can be seen. In 18% of women with retracted strings perforation is present. The uterus is probed to detect the IUD. A plain x-ray of the abdomen is taken to rule out unnoticed expulsion. If the x-ray reveals the IUD, a hysterosalpingogram is performed with both autero-posterior and lateral views using 40% iodized oil. Laparoscopy is performed under general anesthesia with the patient in the lithotomy position. The uterus is manipulated by a tenaculum on the cervix. The abdomen is distended with gas, 3-4.5 liters. The patient is then slowly moved into the Trendelenburg position to allow the omentum and intestines to withdraw from the pelvis. When the IUD is found, it can be grasped by Eder tongs and withdrawn. Lippes Loops were removed from 5 patients by this method. All recovered uneventfully. Left lower quadrant pain was the only symptom complained of before the operation. 1 patient had been pregnant and after a successful delivery the extrauterine IUD was removed 1 day postpartum. Laparoscopy produces minimal surgical trauma, the postoperative course is short, and morbidity has not been encountered. Tubal coagulation could be done at the same time if desired.^ieng

Suppurative salpingitis after laparoscopic tubal cauterization.

PIP: 3 case reports of suppurative salpingitis after laparoscopic tubal cauterization taken from a series of over 1800 such operations at the University of Michigan Medical Center are presented and examined for similar clinical characteristics that may suggest a common pathogenesis. In each case an intrauterine device was present until the time of surgery and in each case a uterine curettage had been done. The delay between the operation and the onset of the salpingitis symptoms ranged from 4-8 days. Pelvic surgery was necessary in 2 cases but high dosages of multiple antibiotics corrected the condition in the third patient. Though only 3 cases are involved, the presence of the IUD must be suspected as a possible cause of the infection, since these devices have caused similar physiologic reactions under other conditions. Removal of the IUD several weeks before tubal cauterization or prophylactic antibiotic treatment should be considered in patients with an IUD in situ undergoing this operation.^ieng

Perforation of the uterus and partial extrusion of a Lippes loop. Report of a case.

PIP: This is a case report of a woman having an IUD which became partially extruded through the uterine wall and went undetected until the patient became pregnant. Severe metritis followed premature rupture of the membranes during the early part of the third trimester. Cesarean section hysterectomy led to a salutary outcome.^ieng

Ectopic endometrium in omentum. Uterine perforation by Lippes loop.

A case of ectopic endometrium in the omentum following perforation of the uterus by a Lippes Looptm is reported. Evidence is presented substantiating Sampson's theory of endometrial implantation.

PIP: This is a case report of a patient who had an IUD inserted the year following a spontaneous abortion. The next year she became pregnant and delivered a full-term infant. Another IUD was then inserted. After 2 years lower abdominal pain and vaginal bleeding of 2 months duration caused her to ask to have the IUD removed. The thread broke during the removal attempt so the patient was admitted to the hospital where a hysterogram revealed a Majzlin spring partially embedded in the uterine wall and a Lippes loop outside the uterine cavity. The Majzlin spring was removed through the vagina and curettage done. At laparotomy to remove the other IUD the Lippes loop was found embedded in a large mass of omentum. The loop and adherent omentum were removed. Histologic study revealed an area of well-preserved endometrium, an area of hemorrh agic endometrium with leukocytic infiltration, and dense fibrous tissue surrounding the endometriotic foci. These findings support the theory of endometrial transplantation rather than the theory of metaplasia.

Intrauterine contraceptive devices: a comparison between their use in indigent and private patients.

PIP: Use of intrauterine contraception for an aggregate 8291 months in a group of 706 private patients (mean age 27.5 years, mean number of pregnancies 2.75, 9 nulligravidas) was analyzed and compared briefly with use in a group of 623 women from a lower socioeconomic level. Considering private patients only, 195 (27.6%) had intermenstrual bleeding after IUD insertion and 27 (3.8%) experienced an increase in the amount or duration of menstrual flow. All women had cramping after insertion of the Lippes loop (or Permaspiral in 2 patients); 43 (6.1%) expelled the device. Infection developed in 9 (1.3%), and perforation of the uterus during insertion of the loop occurred in 2 patients. The pregnancy rate for all users was 2.6 pregnancies per 100 years of use. Termination of intrauterine contraception in 216 (30.6%) was because of intermenstrual bleeding (89 women), increased menstrual flow (7), cramping (19), infection (8), spontaneous ejection (22), a sterilizing operation on either spouse (8), pregnancy when IUD inserted (2), pregnancy desired (37), and other personal reasons (6). The IUD continued to be acceptable to 535 (75.8%, including those sterilized or desiring pregnancy) of 706 upper and middle class women an aggregate of 6655 months of use. Private patients compared to clinic ones had a lower incidence of irregular bleeding (195 of 706 vs. 391 of 623), but more of them discontinued intrauterine contraception because of irregular or excessive bleeding (96 or 13.6% of private patients vs. 28 or 4.5% of clinic patients). The infection rate, total expulsion rate, and final rate for discontinuation due to expulsion were lower for private vs. clinic patients (1.3% vs. 8%, 6.1% vs. 15%, and 3% vs. 5.7%, respectively). It was found that the main advantage of the IUD, constant unburdensome protection against pregnancy, was important to both groups and that couples of any social class could effectively use intrauterine contraception. Differences in use are due to lesser dependence on the IUD among upper strata women, who can use other contraceptive methods successfully.^ieng

Effect of anovulatory drugs on the human urinary tract and urinary tract infections.

PIP: Over a 1-year period, 44 women using either Demulen, Deladroxate or the Lippes loop were studied at the University of Pennsylvania for urinary tract disorders. Monthly catheterized urine specimens were cultured and examined cytologically. Excretory urograms and serum creatinine examinations were performed 1 month prior to and 6 and 12 months after contraceptive initiation. No effect on the urinary tract was observed by X-ray studies. All serum creatinines remained normal. Urine sediments showed cytologic patterns consistent with phase of cycle. Incidence of asymptomatic bacteriuria was 6.8% initially and 11% during the course of study. Only 1 Demulen patient developed asymptomatic tract infection. Urographic abnormalities were found in a certain percentage of women of reproductive age irrespective of contraceptive use. Study results, are confirmed by urograms of family planning clinic patients, indicate that estrogen-progestogen contraceptives appear to have little significant effect on human tract anatomy or infection rate.^ieng

Actinomyces and an unidentified ameba associated with an intrauterine device.

PIP: A case report is presented of an asymptomatic 29-year-old Hawaiian patient with an IUD who had Actinomyces and an unidentified ameba in a Papanicolaou smear and in whom both organisms disappeared upon removal of the IUD. The patient presented for a routine pelvic examination as part of an employment physical. She denied any significant gastrointestinal or vaginal symptoms as well as any history of foreign travel. The patient reported that she had worn the same IUD for 9 years and that it had caused her no discomfort. A pelvic examination revealed a friable, papular cervix. The Papanicolaou smear revealed the presence of both amebae and colonies of Actinomyces. The findings were confirmed by the Armed Forces Institute of Pathology, which reported an intense, acute and chronic inflammatory reaction marked by the presence of amebae and Actinomyces species colonies. The patient returned 4 months later for a repeat pelvic examination and removal of her IUD. At that time a cervical smear showed only amebae. The patient was seen again 3 months following the IUD removal. She reported that her vaginal discharge had decreased. A repeat Papanicolaou smear was completely normal. Faulkner and Ory have reported a 5-fold increase of pelvic inflammatory disease among IUD users compared to nonusers. Among pelvic infections found to be associated with IUD users is genital actinomycosis. Many of these patients are asymptomatic with only cytologic evidence of Actinomyces, but these patients can progress to pelvic inflammation and abscess formation. Reports have recently described the presence of amebic trophozoites in IUD users. The main purpose in reporting this case is to alert the tropical medicine specialist to this entity. Amebic colonization appears to respond completely to IUD removal, and there is no need for additional medical or surgical treatment.^ieng

Effects of contraceptive pills and intrauterine devices on urinary bladder.

The incidence of bacteriuria and cystoscopic changes in women on oral contraceptives or users of IUD (intrauterine devices) were evaluated compared with a control group. Subjects with bacteriuria accounted for 40.5 per cent of pill users, 20 per cent of women fitted with IUD, and 16 per cent of the control group. Bladder trabeculations were found in 50.5 per cent of the pill group, 8.7 per cent of the IUD group, and 8 per cent of the controls. Congested bladder trigone was observed in 24.6 per cent of women fitted with an IUD. The mode of action of ovarian hormones and their possible side effects on the bladder are discussed. The relation of IUD to pelvic inflammatory disease and its effect on the urinary bladder are evaluated.

PIP: The incidence of bacteriuria and cystoscopic changes in 200 women using oral contraceptives from 1 month to 2 years and 150 users of IUD were compared with 50 women using neither method. Bacteriuria in midstrean urine samples of all subjects were identified qualitatively and quantitatively by the method of Stamey et al. Cystoscopy was performed on all subjects. Positive bacteriuria were found in 40.5% of patients on oral contraceptives, 20% of IUD users, and 16% of the control group. Positive pathogenic bacterial cultures in women using oral contraceptives were proportional to the length of time the pill had been used: 27% for 1 year users, 35% for 2 year users, and 50% for longer users. The potency and dosage is correlated with the pathogenic effects observed. Bladder trabeculations were found in 50.5% of oral contraceptive users, 8.7% of IUD users, and 8% of control subjects. The highest incidence was in subjects using pills for 2 years or more, and is correlated with the dosage used. Bladder trigone congestion was observed in 24.6% of IUD users; 56% of users from 1 to 3 months, 35% of users more than 2 years, and no users between these time extremes. The high incidence of bladder trabeculations might be explained by the effect of progestogens and estrogens on bladder tone; progestogens producing hypotonia and estrogens hypertonia. The IUD should not be used more than 2-3 years continuously to avoid urinary bladder effects and inflammatory pelvic disease.

Clinical significance of the androgenicity of progestins in hormonal therapy in women.

Optimal efficacy has been achieved in both oral contraception and postmenopausal replacement therapy. The current challenge is to minimize the side effects and metabolic impact of the administered hormones in both oral contraceptives and hormone replacement agents. When the dose of estrogen in oral contraceptives was reduced the risk of thromboembolism decreased, but the androgenic side effects of the progestin became increasingly apparent. The addition of progestins to hormone replacement therapy reduces the risk of endometrial cancer associated with unopposed estrogen, but their androgenicity offsets the favorable effects of estrogen on lipid metabolism. Androgens not only cause troublesome clinical side effects but also induce changes in blood levels of lipoproteins that have been associated with an increased risk of atherogenesis and coronary heart disease, as well as alterations in glucose and insulin levels. Both the side effects and the adverse effects on lipoprotein and glucose metabolism can be reduced by the use of less androgenic progestins.

PIP: In order to offset the undesirable clinical effects of progestins in oral contraceptives (OCs) or in hormone replacement therapy, effort has been made to reduce the amount of progestin used and to use progestins with lower androgenicity. It is pointed out that the androgenicity is related to the structural relationship between progestins and 19-nortestosterone. Based on the relative binding affinities (RBAs) for rat prostatic androgen receptors and for sex hormone binding globulin (SHBG), it has been noted that levonorgestrel, which is the active isomer of norgestrel, has twice the androgenicity of norethisterone. There have been research results which confirm OCs with progestins with reduced androgenicity; research shows norethindrone in Ortho-Novum 7/7/7 and levonorgestrel in Triphasil both minimize the effect on lipid metabolism. Another study shows only those more androgenic progestins reduce HDL. The newest low dose progestins in OCs are norgestimate, desogestrel, and gestodene. The action of progestins is on lipid and carbohydrate metabolism.

The "forgotten" intrauterine device.

It is essential to ascertain that women who had an IUD inserted at some time have indeed had the device removed. It is also important to ensure that the whole IUD was removed and that no parts were left in the uterine cavity. This is especially true in cases of infertility and should be ascertained before invasive investigations such as hysterosalpingography or laparoscopy commence. An accurate history and ultrasonography can easily rule out a forgotten or fragmented IUD, thereby preventing considerable unnecessary suffering and expense.

PIP: This article presents 3 cases that illustrate a generally overlooked complication of IUD use: a device that is forgotten by the patient and gynecologist and remains in the uterus. The cases demonstrate the need to ensure that women who have had an IUD inserted at some point have indeed had the device removed. It is especially important to ensure that there is no IUD in utero in the following 2 situations: 1) women who claim or were told the IUD fell out or in cases where the suspected spontaneous loss of an IUD was not documented radiographically; and 2) women referred for infertility investigation, who previously had an IUD and in whom removal of an intact device is not documented by a physician's report or gross pathology report. An accurate history and ultrasonography can easily rule out a forgotten or fragmented IUD, thereby preventing considerable unnecessary testing and expense.