1. PELVIC INFLAMMATORY DISEASE AND SEXUALLY TRANSMITTED INFECTIONS
Rebecca Mercier MD, MPH
Assistant Professor, Obstetrics and Gynecology

2. OUTLINE! Epidemiology of STIs Basics of testing/screening
Pelvic Inflammatory Disease
Diagnosis, treatment
The Major STIs:
Chlamydia
Gonorrhea
Trichomonas
HSV
HPV/Warts
*Syphillis and Chancroid covered in handout

3. Women as the vectors….

4. But men play their part.

5. STIs in the US
CDC Fact Sheet: Incidence, Prevalence and Cost of Sexually Transmitted Infections in the United States

6. STIs in the US
CDC Fact Sheet: Incidence, Prevalence and Cost of Sexually Transmitted Infections in the United States

7. Taking a STI History The Five Ps 1. Partners
2. Prevention of pregnancy
3. Protection from STDs
4. Practices
5. Past History of STDs

8. Education INTERACTIVE COUNSELING
Patient–centered Counseling most effective
Requesting testing? Concern about exposure? Declining testing? Why?

9. Testing: Who
CDC recs annual screening, at least of gc/ct for age <25
At other ages: risk based!
Make sure a patient understands what specific STIs she was screened for
Plan a follow up visit to discuss results
Offer recommendations for partner testing
And possibly partner treatment!

10. Testing: How IN PERSON LAB TESTING Thorough vulvar examination
Pelvic Exam
Swab/Microscopy
Gonorrhea
Chlamydia
Trichomoniasis
LAB TESTING
HIV (consent required)
RPR
HBsAg
HCAb
HSV Type 1&2 IgG
HSV not usually screened

11. Pelvic Inflammatory Disease

12. PID: General Most significant sequelae of untreated GC/CT; though
ONLY 2/3 of PID cases related to STIs
Tubal factor infertility, ectopic pregnancy, chronic pelvic pain
Diagnosis is imprecise
Negative NAAT for GC/CT do not exclude the diagnosis
Empiric therapy

13. PID-Epidemiology Chlamydia-delayed inflammatory response
Up to 11 days AFTER treatment
Promotion of scar tissue
Gonorrhoea-immediate inflammatory response
1 episode = 15% tubal factor infertility
But not just STIs!

14. PID-Epidemiology Protective Factors
Cervical Mucus-thicker in second half of menstrual cycle and resists upward movement of bacteria
OCPs and other BCMs -thicken cervical mucus
Tubal Ligation
Pregnancy

15. PID-Diagnosis: Clinical
At least one of the following:
cervical motion tenderness or
uterine tenderness or
adnexal tenderness
One or more of the following support diagnosis:
oral temperature >101° F (>38.3° C);
abnormal cervical or vaginal mucopurulent discharge;
presence of abundant numbers of WBC on saline microscopy of vaginal fluid;
elevated erythrocyte sedimentation rate;
elevated C-reactive protein; and
laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.

16. PID-Diagnosis: Other Most specific diagnostic criteria
endometrial biopsy with histopathologic evidence of endometritis;
transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or Doppler studies suggesting pelvic infection (e.g., tubal hyperemia); or
laparoscopic abnormalities consistent with PID

17. PID-Diagnosis
Clinical Diagnosis has 65-90% PPV when compared to Laparoscopy (gold standard)
Many cases still go unrecognized: have LOW THRESHOLD FOR DIAGNOSIS
THE CLINICAL FINDINGS ARE ENOUGH!!! For mild to moderate PID no imaging is necessary : but consider if no improvement in 48hours

18. PID-Diagnosis May be confused with other conditions: Appendicitis
Diverticulitis
Endometriosis
Ruptured ovarian cyst

19. PID: Treatment Out patient management preferred for mild cases:
Ceftriaxone 250mg intramuscularly single dose
AND
Doxycycline 100mg orally twice a day for 14 days
AND MAYBE
Metronidazole (Flagyl) 500mg orally twice a day for 14 days

20. PID-Criteria for Admission
surgical emergencies (e.g., appendicitis) cannot be excluded;
pregnant
failed outpatient oral therapy;
unable to follow /tolerate an outpatient oral regimen;
the patient has severe illness, nausea and vomiting, or high fever;
the patient has a tubo-ovarian abscess

21. PID Treatment-Inpatient
Recommended Parenteral Regimen A
Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours AND Doxycycline 100 mg orally or IV every 12 hours

22. PID Treatment-Inpatient (2)
Recommended Parenteral Regimen B
Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3–5 mg/kg) can be substituted.
Alternative Parenteral Regimens
Ampicillin/Sulbactam 3 g IV every 6 hours AND Doxycycline 100 mg orally or IV every 12 hours

23. PID Sequelae Peri-hepatitis TOA Infertility Ectopic pregnancy
Recurrent infection
Chronic pain

24. Chlamydia

25. Chlamydia Most prevalent bacterial STI
Estimated 2 million cases annually
70% asymptomatic
Cervicitis with a mucopurulent discharge

26. Chlamydia
Screening is recommended for all women less than 25 years old and older women with risk factors
Nucleic Acid Amplification Test (NAAT) recommended
Test of Cure (TOC) not necessary unless the patient is pregnant
Rescreening at 3 months
Partner Treatment

27. Chlamydia Treatment: Recommended:
Azythromycin 1 gram po in a single dose OR
Doxycycline 100mg orally twice a day for 7 days

28. Chlamydia Treatment: Alternates:
Erythromycin base 500 mg orally 4 times a day for 7 days
Erythromycin ethylsuccinate 800mg orally 4 times a day for 7 days
Ofloxacin 300mg orally twice a day for 7 days
Levofloxacin (Levaquin) 500mg orally once daily for 7 days

29. Gonorrhea

30. Gonorrhea Less common 350,000 reported cases/year 50% asymptomatic
Cervicitis, PID
Screening recommendations similar to Chlamydia

31. Gonorrhea Treatment Preferred Regimen:
Quinolone resistance – Don’t use!
Emerging resistance to cephalosporins and tetracyclines are a real concern
Preferred Regimen:
NEW CDC RECCOMENDATION:
Ceftriaxone 250 mg intramuscularly in a single dose
AND
Azithromycin 1gram PO
Or doxycycline 100mg po BIC x 7 days

32. Gonorrhea Alternative regimens: depends on the reason!
Alternative treatment? Test of cure in 1 week!
If ceftriaxone is not available
Cefixime 400mg po single dose
PLUS
Azithromycin 1g po x1 OR Doxy 100mg BIDx7days
If severe cephalosporin allergy
Azithromycin 2g po x1

33. Trichomonas

34. Trichomonas 7.4 million cases in US annually
Characterized by vaginal discharge, itching, burning or post-coital bleeding - classic “strawberry cervix”
Diagnosis:
Wet mount 60% sensitivity
Culture – 90% sensitivity
OSOM Rapid test – 88% sensitivity

35. Trichomonas Diagnosis on pap test Latency:
False positives are common: 8% for conventional pap and 4% for liquid based
If pap indicates Trichomonas, a wet mount or NAAT should be performed
Latency:
Asymptomatic carriage is common
Recent diagnosis does not equal aquisition

36. Trich Treatment Preferred: Alternative: Note:
Metronidazole 2 grams orally single dose OR
Tindazole 2 grams orally single dose
Alternative:
Metronidazole 500mg orally twice a day for 7 days
Note:
SE: disulfuram-like reaction. Avoid alcohol for 24/72hrs
No other alternative treatments: desensitize allergic patients
Topical gel significantly less effective

37. Genital Herpes

38. Herpes Most common STD in the US?
Not reportable, so numbers less reliable than for other STIs. Estimates:
50 million Americans have HSV
1 million new cases a year
90% of infected individuals are unaware

39. Why don’t people know? HSV can be a very subtle infection
misdiagnosed
Outbreaks are not always “genital”
Patient may have protection from genital herpes due to oral lesions

40. Testing for HSV: Lesions
Clinical diagnosis only 40% sensitive
PCR with typing (not approved by FDA)
Culture for HSV with viral typing
Culture misses ¾ of cases determined by PCR
Same collection, different check box

41. Testing for HSV: Serology
If no lesion present:
Serum IgG for HSV 1 and 2
50% seroconvert by 3 weeks; Nearly 100% seroconvert by 4 months
Who can/should get serology?
Previous/current partner with genital HSV
Uncertain diagnosis: Negative swab test of lesion, recurrent non- specific symptoms
Previous diagnosis and wants serotyping
Sexual assault
Pregnancy (controversial)

42. Asymptomatic shedding
15-20 of days with genital HSV 2
Responsible for 70% of new transmission
Reduced by 80% with suppressive therapy

43. Treatment: 3 reasons/regimens
1st episode
Acyclovir 400mg orally three times daily for 7-10 days
Valacyclovir (Valtrex) 1000mg orally twice daily for days
Famciclovir (Famvir) 250mg orally three time daily for 7- 10
Topical Acyclovir doesn’t add anything
Local care
Analgesics

44. Treatment
Episodic:
Acyclovir 400mg orally three times daily for 5 days
Valacyclovir (Valtrex) 500mg orally twice daily for 3 days
Famciclovir (Famvir) 125mg orally twice daily for 5 days
Most effective if started with prodrome

45. Treatment Suppression: Candidates for suppressive therapy:
Acyclovir 400mg orally twice a day
Valacyclovir 500mg orally daily if </= 9
Valacyclovir 500mg twice a day OR 1000mg once a day orally if >9
Famciclovir 250mg orally twice a day
Safety data available for 20 years. No surveillance labs or drug holidays required.
Prevents 80% of recurrences
Reduction in asymptomatic shedding decreases transmission 48%
Candidates for suppressive therapy:
Negative partner; Multiple partners; Bothered by outbreaks; New diagnosis; Pregnant at 36 weeks

46. End Note…….
The diagnosis of HSV is often overwhelming to patients. The diagnosis necessitates a great deal of education and decision making. Make a follow up visit.

47. Genital Warts

48. Genital warts
Four types: condylomata acuminata, papular warts, keratotic warts, flat-topped papules
Multiple lesions common
Asymptomatic, itching, burning, pain, bleeding
Broad differential diagnosis warrants liberal use of biopsy if diagnosis unclear
HPV 6 and HPV 11
Immunosuppression

49. Evaluation Thorough inspection of vulvar and perianal area
Vaginal and cervical inspection
Pap smear (if not up to date)
Colposcopy (if cervical warts)

50. Treatment Response rates / timecourse
Patient applied treatment vs provider administered
Mechanical measures

51. Patient Applied Podofilox 0.5% Imiquimod 5%
Purified from podophyllin resin
Apply twice daily for four days
Use for 4 weeks
No need to wash off
Apply with cotton swab
Imiquimod 5%
Immune response modifier
Every other day
16 weeks
Wash off 6-10 hours after application
Apply with finger tip

52. Provider Administered
Podophyllin Resin
antimitotic
Wash off 1-4 hrs later
Apply 1-2 times per week up to 6 weeks
Limit to 0.5ml or 10 cm3 to prevent bone marrow depression
Trichloracetic Acid
Destructive agent
Apply weekly
Weekly for up to 6 weeks

53. The secret of the care of the patient is IN caring for the patient.
Francis W. Peabody,