)19C-4,&61=-9:1;@)19C-4,&61=-9:1;@
1/1;)475576:)19C-4,1/1;)475576:)19C-4,
!<9:16/)6,-)4;0$;<,1-:)+<4;@
"<*41+);176:
)9176"-+30)5/)6$+07747.!<9:16/)6,
-)4;0$;<,1-:
6;9)<;-916--=1+-:16;0-76;-?;7.767+7++)46.-+;1766;9)<;-916--=1+-:16;0-76;-?;7.767+7++)46.-+;176
04)5@,1)46.-+;176)6,"-4=1+6D)55);79@1:-):-!7;04)5@,1)46.-+;176)6,"-4=1+6D)55);79@1:-):-!7;
<;<)44@?+4<:1=- <;<)44@?+4<:1=-
091:;):87:1;7
)19C-4,&61=-9:1;@
+091:;)-:87:1;7.)19C-4,-,<
7447>;01:)6,),,1;176)4>793:);0;;8:,1/1;)4+75576:.)19C-4,-,<6<9:16/.)+<4;@8<*:
B*@;0-5-91+)6744-/-7.!<9:-‐ 1,>1=-:4491/0;:9-:-9=-,
%0-87:;8916;=-9:1760):*--6)9+01=-,0-9->1;08-951::176.975;0-+78@91/0;074,-9<6,-9)
(!!41+-6:-
"--9#-=1->-,"--9#-=1->-,
#-87:1;79@1;);176#-87:1;79@1;);176
:87:1;7091:;)6;9)<;-916--=1+-:16;0-76;-?;7.767+7++)46.-+;17604)5@,1)46.-+;176)6,
"-4=1+6D)55);79@1:-):-!7; <;<)44@?+4<:1=-
!<9:16/)6,-)4;0$;<,1-:)+<4;@
"<*41+);176:
0;;8:,1/1;)4+75576:.)19C-4,-,<6<9:16/.)+<4;@8<*:
"<*41:0-,1;);176
:87:1;7091:;)")4)6+1)6;9)<;-916--=1+-:16;0-76;-?;7.767+7++)46.-+;17604)5@,1)46.-+;176)6,
"-4=1+6D)55);79@1:-):-!7; <;<)44@?+4<:1=-7<96)47. 1,>1.-9@'75-6:-)4;067
0;;8:,7179/25>0
%01:1;-50):*--6)++-8;-,.7916+4<:176161/1;)475576:)19C-4,*@)6)<;0791A-,),5161:;9);797.
1/1;)475576:)19C-4,;1:*97</0;;7@7<*@1/1;)475576:)19C-4,>1;08-951::176.975;0-91/0;:
074,-9:)6,1:897;-+;-,*@+78@91/0;)6,799-4);-,91/0;:(7<)9-.9--;7<:-;01:1;-516)6@>)@;0);1:(7<)9-.9--;7<:-;01:1;-516)6@>)@;0);1:
8-951;;-,*@;0-+78@91/0;)6,9-4);-,91/0;:4-/1:4);176;0);)8841-:;7@7<9<:-797;0-9<:-:@7<6--,;77*;)168-951;;-,*@;0-+78@91/0;)6,9-4);-,91/0;:4-/1:4);176;0);)8841-:;7@7<9<:-797;0-9<:-:@7<6--,;77*;)16
8-951::176.975;0-91/0;:074,-9:,19-+;4@<64-::),,1;176)491/0;:)9-16,1+);-,*@)9-);1=-75576:41+-6:-8-951::176.975;0-91/0;:074,-9:,19-+;4@<64-::),,1;176)491/0;:)9-16,1+);-,*@)9-);1=-75576:41+-6:-
16;0-9-+79,)6,7976;0->7931;:-4.16;0-9-+79,)6,7976;0->7931;:-4.79579-16.795);17684-):-+76;)+;,1/1;)4+75576:.)19C-4,-,<
Intrauterine Devices in the Context of
Gonococcal Infection, Chlamydial Infection, and Pelvic Inflammatory Disease:
Not Mutually Exclusive
Abstract
The use of long-acting reversible contraception (LARC), namely intrauterine device (IUDs) and
the subdermal implant, has been recommended to address the high rate of the unintended
pregnancy in the United States. IUDs are a safe, highly effective contraceptive method, suitable
for most women. The underutilization of IUDs arises in part from the lack of translation of best
practices in the clinical setting as well as fears and misperceptions about this contraceptive
method held by health care providers and women. This article reviews screening and
management of Neisseria gonorrhoeae and Chlamydia trachomatis infection and pelvic
inflammatory disease in women who are using or want to use an IUD. An IUD may be inserted
without prior screening for N gonorrhoeae or C trachomatis in low-risk, asymptomatic women.
trachomatis, or pelvic inflammatory disease (PID). The risk of PID with an IUD in situ is less
than 1%. Following IUD best practices, including their use in the context of sexually transmitted
infections, can increase the availability of this method for suitable candidates and decrease the
unintended pregnancy rate.
Keywords: Intrauterine device (IUD), long-acting reversible contraception (LARC),
contraception, unintended pregnancy, sexually transmitted infections, Neisseria gonorrhoeae,
Chlamydia trachomatis, pelvic inflammatory disease
2
Case Report
K.V. is 22-year-old woman who presents for her annual gynecological examination with
her certified nurse-midwife (CNM). She had an induced abortion at a nearby clinic 3 months ago
with no complications. She was prescribed oral contraceptive pills (OCPs) at the clinic but
missed “a bunch” so stopped taking them. She is currently not using any form of contraception
and would like to resume OCPs. K.V. had an appendectomy at age 12. She has no other
obstetric history or health conditions. She is heterosexual and intermittently sexually active with
the same partner for over two years. She reports no history of sexually transmitted infections
(STIs) or pelvic inflammatory disease (PID).
Findings from the physical examination are normal, and a urine pregnancy test is
negative. Neisseria gonorrhoeae and Chlamydia trachomatis tests were negative at her last visit
one year ago and repeated at this visit. K.V. has no known contraindications to any
contraceptive methods.
Contraceptive options are discussed at length, including risks and
benefits, and K.V. decides she would like an intrauterine device (IUD). She is scheduled to
return to the office for the IUD insertion in 2 weeks, which should coincide with her menses.
K.V.’s C trachomatis test is positive. Azithromycin (Zithromax) is prescribed, and her IUD
insertion visit that was scheduled for 2 weeks later is canceled. No follow-up appointment is
made, and K.V. has no reliable contraception. When the CNM learns of the situation 2 days
later, she calls K.V. and explains that she can still have the IUD placed and that her infection
will be cured before the date of the insertion.
1,2
K.V. is hesitant to reschedule her IUD
placement because she is worried about the risk of PID. The CNM advises K.V. that the risk of
PID with an IUD is less than 1%
1,3
and reassures her of the efficacy and safety of the IUD. With
K.V.’s continued uncertainty, the CNM offers her an appointment to revisit her contraceptive
options and a prescription for an OCP for the interim. She encourages K.V. to use condoms to
protect herself against pregnancy and STI.
4,1
K.V. declines an office visit and OCP prescription
stating she will consider all her options and call back. K.V. never calls the office and does not
respond to messages left by the CNM.
This case report is a composite of elements from different patients.
3
Introduction
In the United States, the unintended pregnancy rate is the highest for women between the
ages of 20 and 25 years, at 81%.
5
The Healthy People 2020 initiatives to decrease unintended
pregnancy and increase the use of long-acting reversible contraception (LARC), including the
intrauterine device (IUD) and implant, call upon women’s health care providers to offer effective
contraception to appropriate candidates.
6
The rate of unintended pregnancy may be reduced by
women’s health care provider IUD counseling and provision.
7
In the context of the STIs N
gonorrhoeae and C trachomatis, some health care providers may not to adhere to IUD best
practices.
8
This article reviews evidence-based care for women with, or seeking, an IUD while
experiencing a N gonorrhoeae or C trachomatis infection or PID.
Intrauterine Devices
LARC methods are 20 times more effective than other forms of contraception, such as
OCPs.
9
IUD insertion is an in-office procedure with few contraindications.
9
There are currently
5 IUDs available, 4 levonorgestrel-releasing IUDs varying in size and dose and one hormone-
free, copper IUD.
9
These IUDs are effective for between 3 and 10 years, depending on the type.
9
Although LARC methods have a failure rate of less than 1%, they are underutilized,
particularly in US women aged younger than 25 years.
10,11
Overall use of IUDs among US
women is 11.8%.
12
The underutilization of IUDs stems, in part, from misinformation and fears
about this method held by both health care providers and women.
5,13
Some health care providers
limit the use of IUDs due to a perceived risk of STIs, PID, and the possibility of subsequent
ectopic pregnancy and infertility.
14
While some health care providers and women remember an
older generation of IUDs, such as the Dalkon Shield in the 1970s, that were linked with these
complications, research on the currently available IUDs has found that they are safe, even with
the diagnosis of a concomitant STI.
1,15,16
Women report the lack of information and access to appropriate contraceptive methods,
especially the IUD, as barriers to the use of highly reliable contraception.
13,17
Reluctance to use
an IUD has been linked to “horror stories” communicated via friends and the media, fear of pain
with insertion, fear of impairing future fertility, and historical injustices concerning the
sterilization of Native American and black women.
13,17
Some US women perceive a lack of
contraceptive autonomy, particularly when they sense contraceptive coercion by their
4
provider.
11,17
There may also be a perception of provider biases against socially marginalized
women.
17
Women of varying races report a sense of distrust in their provider, specifically when
their provider is reluctant to remove LARC when requested.
17
Through shared decision making,
women’s health care providers can dispel misconceptions and offer unbiased, noncoercive,
evidence-based information to facilitate a suitable contraceptive choice.
13,17
Candidates for Intrauterine Device Use
IUDs are an appropriate contraceptive method for most women, regardless of their age,
parity, and history of STIs and ectopic pregnancy.
6,15
The US Medical Eligibility Criteria for
Contraceptive Use (US MEC) is an evidence-based resource that summarizes recommendations
for the safe use of contraceptive methods in the presence of medical conditions, such as migraine
headache or diabetes, and other health characteristics, such as breastfeeding or medication use.
15
The US MEC classifies the use of each method of contraception on a scale of 1 to 4; a method
categorized as a 1 may be used without reservation, a Category 4 indicates use of the
contraception poses an unacceptable risk (see Table 1).
15
IUD use is further categorized in terms
of its initiation and continuation. Broadly speaking, IUD initiation and continuation is deemed
acceptable (Category 1, 2, or 3) in most situations.
15
IUD initiation is an unacceptable risk
(Category 4) in the presence of a known or suspected active cervical or uterine infection, certain
malignancies, and uterine anomalies.
15
A consideration of IUD use in adolescents and women aged younger than 25 years is the
risk of STIs and potential for PID. This age group has the highest risk of acquiring N
gonorrhoeae and C trachomatis.
1
IUDs do not protect against STIs; condoms are recommended
for concomitant use.
1,3
N gonorrhoeae and C trachomatis are among the leading causal agents
for PID; however, having a history of either of these STIs is not a contraindication for IUD
initiation or continuation.
1,15
Likewise, women with a history of ectopic pregnancy or PID
treated more than 3 months ago may be candidates for an IUD.
1,15
In the presence of a known or
suspected N gonorrhoeae or C trachomatis infection or PID, IUD insertion is delayed until
screening is performed and/or treatment is completed.
1,15
In the absence of a known cervical or
uterine infection or purulent cervical discharge, an IUD may be inserted with an unknown N
gonorrhoeae and C trachomatis status.
1,15
5
Screening and Treatment for N gonorrhoeae or C trachomatis with Intrauterine Device Use
N gonorrhoeae and C trachomatis may present asymptomatically, or mucopurulent
cervical discharge, intermenstrual bleeding, or a friable cervix may be detected.
1
N gonorrhoeae
and C trachomatis may be detected through a nucleic acid amplification test (NAAT) of an
endocervical or vaginal swab specimen or a first-void urine specimen at the time of IUD
insertion.
1
C trachomatis is treated with a one-time 1 g oral dose of azithromycin.
1
N
gonorrhoeae is treated with a one-time dose of ceftriaxone (Rocephin) 250 mg intramuscularly
and azithromycin 1 g orally, due to the incidence of concomitant C trachomatis infection.
1
There are acceptable alternatives to these regimens (see Table 2).
1
N gonorrhoeae and C
trachomatis are considered cured one week after treatment.
1
Therefore, the insertion of an IUD
may proceed one week after the diagnosis and treatment of these infections. If an IUD is in situ,
it may remain in place during the treatment of N gonorrhoeae and C trachomatis.
1
Rescreening
for N gonorrhoeae and C trachomatis after treatment should take place in 3 months, unless
reinfection is suspected sooner, but no sooner than 3 weeks after treatment to avoid a false-
positive from nonviable organisms still present in the vagina.
1
Treatment of Pelvic Inflammatory Disease in Women with an Intrauterine Device
PID is caused by a myriad of bacteria in the genital tract, including N gonorrhoeae and C
trachomatis.
1
The presentation of PID can be vague but often includes pelvic or low abdominal
pain.
1
A low threshold for diagnosis and treatment should be practiced to avoid the potential
sequelae of PID, including ectopic pregnancy and infertility.
1
The minimum criteria for the
diagnosis of PID is the presence of any one of the following: uterine tenderness, cervical motion
tenderness, or adnexal tenderness.
1
Other signs may include fever (temperature > 101
o
F),
purulent cervical discharge, cervical friability, and elevated C-reactive protein or erythrocyte
sedimentation rate values.
1
Treatment regimens for uncomplicated, mild to moderately severe
PID are presented in Table 3.
1
Inpatient intravenous therapy is warranted in severe cases with
high fever, nausea, vomiting, tubo-ovarian abscess, inability to tolerate oral treatment, or lack of
response to oral or intramuscular antibiotics.
1
IUD insertion is contraindicated in women with current PID.
1
If a woman who has an
IUD develops PID, her IUD does not have to be removed.
1
The removal of an IUD does not
affect the course of active PID.
15
IUD removal is indicated if PID is unresponsive to treatment or
6
the woman desires removal (see Figure 1).
1,3
When IUD removal is needed, it should be delayed
until 48 to 72 hours after the initiation of antibiotics to prevent dissemination of the infection.
1,15
Implications for Clinical Practice
This case report highlights the use of IUDs in the context of STIs and PID and the need
for women’s health care provider education and translation of best practices into clinical
practice.
18,19
Midwives have a role in the ongoing education of the interprofessional women’s
health care team. Consistency in women’s health care providers’ translation of IUD best
practices into clinical practice needs improvement.
8,20
It is important to ensure all health care
providers, including those who provide primary and pediatric care, are aware the use of IUDs is
recommended for young women and that STIs are not a contraindication for IUD use or
continuation.
1,15,21
A woman’s lifelong contraceptive decision making is facilitated by her health care
provider and her health care provider’s recommendations.
22
Women’s health care providers can
ensure access and provision of desired contraception at every visit. A recent study found that
almost 25% of eligible women (n = 305) did not receive any form of contraception over the
course of 450 cumulative visits to a health care setting.
20
This study highlights the missed
opportunity for contraception provision by women’s health care providers.
20
Ongoing women’s health care provider LARC training has increased health care provider
IUD knowledge and utilization.
18,19
A free, publicly available resource that can be used for
health care provider training and dissemination of IUD best practices is the American College of
Obstetricians and Gynecologists (ACOG) LARC Video Series.
9
This set of videos covers
various topics including IUD candidacy, counseling, informed consent, and clinical
management.
9
With women’s health care providers’ implementation of current IUD best
practices, women may realize increased access to appropriate contraception, which can decrease
the rate of unintended pregnancy.
Conclusion
In the United States, unintended pregnancy is a persistent public health problem. Providing
appropriate contraception can prevent unintended pregnancy. While the evidence shows that
most women are candidates and there are few contraindications to IUD use, some health care
7
providers may not offer IUDs to eligible candidates due to fears and lack of knowledge,
particularly in the context of STIs and PID.
9,22
The CDC and ACOG recommend health care
providers offer IUDs as a safe contraceptive method, specifically to young women with the
highest risk of unintended pregnancy.
3.9
History of ectopic pregnancy or PID are not
contraindications for IUD use; IUDs may be inserted in low-risk, asymptomatic women without
prior N gonorrhoeae or C trachomatis screening.
1,15
A diagnosis of N gonorrhoeae or C
trachomatis infection or PID does not require removal of the IUD.
1
Women’s health care
providers serve women best by meeting their contraceptive needs. Implementation of best
practices facilitates the access to and provision of IUDs relative to STIs and PID.
8
References
1. Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment
Guidelines. https://K.V..cdc.gov/std/tg2015/default.htm. Accessed August 26, 2019.
2. Birgisson NE, Zhao Q, Secura GM, Madden T, Peipert JF. Positive testing for neisseria
gonorrhoeae and chlamydia trachomatis and the risk of pelvic inflammatory disease in IUD
users. J Womens Health. 2015; 24(5), 354-359. doi:10.1089/jwh.2015.5190.
3. Curtis KM, Jatlaoui TC, Tepper NK, Zapata LB, Horton LG, Jamieson DJ, et al. U.S.
Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep.
2016; 65(4), 1-66. http://dx.doi.org/10.15585/mmwr.rr6504a1. Accessed January 19, 2020.
4. American College of Obstetricians and Gynecologists. College guidance on annual women’s
health care. https://K.V..acog.org/About-ACOG/ACOG-Departments/Annual-Womens-
Health-Care/College-Guidance-on-Annual-Womens-Health-Care. Accessed January 19,
2020
5. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008-2011.
New Eng J Med . 2016; 374(9): 843-852. doi:10.1056/NEJMsa1506575
6. Healthy People 2020. Washington, DC: U.S. Department of Health and Human Services,
Office of Disease Prevention and Health Promotion.
https://www.healthypeople.gov/2020/topics-objectives/topic/family-planning. Accessed
January 19, 2020.
7. Harper CC, Rocca, CK, Thompson KM, Morfesis J, Goodman S, Darney PD, et al.
Reductions in pregnancy rates in the USA with long-acting reversible contraception: A
cluster randomised trial. Lancet. 2015; 386(9993), 562-
9
568. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)62444-2/fulltext.
Accessed August 23, 2019.
8. Philliber AE, Hirsch H, Brindis CD, Turner R, Philliber S. The use of ACOG guidelines:
Perceived contraindications to IUD and implant use among family planning health care
providers. Matern Child Health J. 2017; 21(9), 1706-1712. https://doi.org/10.1007/s10995-
017-2320-1. Accessed August 23, 2019.
9. American Congress of Obstetricians and Gynecologists. The Long-acting Reversible
Contraception (LARC) Program: LARC Video Series. https://www.acog.org/About-
ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception/LARC-Video-Series.
Accessed January 19, 2020.
10. Trussell J. Contraceptive failure in the United States. J Contracept. 2011; 83(5): 397-404.
Doi:10.1016/j.contraception.2011.01.021
11. Zeal C, Higgins JA, Newton SR. Patient-perceived autonomy and long-acting reversible
contraceptive use: A qualitative assessment in a midwestern, university community. Biores
Open Access. 2018; 7(1), 25-32. doi.org/10.1089/biores.2017.0037.
12. Kavanaugh ML, Jerman, J. Contraceptive method use in the United States: trends and
characteristics between 2008 and 2014. Contraception. 2018; 97(1):14–21.
https://doi.org/10.1016/j.contraception.2017.10.003. Accessed August 23, 2019.
13. Gomez AM, Freihart B. Motivations for interest, disinterest and uncertainty in intrauterine
device use among young women. Matern Child Health J. 2017; 21(9), 1753-1762.
https://doi.org/10.1007/s10995-017-2297-9. Accessed August 23, 2019.
14. Harper CC, Blum M, Thiel de Bocanegra H, Darney P, Speidel JJ, Policar M, et al.
Challenges in translating evidence to practice: The provision of intrauterine contraception.
10
Obstet Gynecol. 2008; 111(6), 1359-1369.
https://journals.lww.com/greenjournal/Fulltext/2008/06000/Obstetrician_Gynecologists_and
_the_Intrauterine.17.aspx. Accessed August 23, 2019.
15. Curtis KM, Tepper NK, Jatlaoui TC, Berry-Bibee, E., Horton LG, Zapata LB, et al. Centers
for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use,
2016. MMWR Recomm Rep. 2016; 65(3), 1-104.
https://www.cdc.gov/mmwr/volumes/65/rr/rr6503a1.htm Accessed January 19, 2020.
16. Lotke PS. Increasing use of long-acting reversible contraception to decrease unplanned
pregnancy. Obstet Gynecol Clin North Am. 2015; 42(4): 557-567. doi:
10.1016/j.ogc.2015.07.008.
17. Higgins JA, Kramer RD, Ryder KM. Health care provider bias in long-acting reversible
contraception (LARC) promotion and removal: Perceptions of young adult women. Am J
Public Health. 2016; 106(11), 1932-1937.
https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2016.303393. Accessed August 23,
2019.
18. Thompson, KM, Rocca, CH, Stern, L, Morfesis, J, Goodman, S, Steinauer, J, et al. Training
contraceptive health care providers to offer intrauterine devices and implants in contraceptive
care: A cluster randomized trial. Am J Obstet Gynecol. 2018; 218(6), 597.e1-e7.
https://doi.org/10.1016/j.ajog.2018.03.016. Accessed July 28, 2019.
19. Esposito CP, LoGiudice JA. Beliefs and use of intrauterine devices among women’s
healthcare providers. J Nurse Pract. 2019; 15(9), 682-687.
doi.org/10.1016/j.nurpra.2019.05.005
20. Santibenchakul S, Tschann M, Carlson ADP, Hurwitz EL, Salcedo J. Promotion of long-
11
acting reversible contraception among adolescents and young adults. J Midwifery Womens
Health. 2019; 64(2): 194-200. https://doi.org/10.1111/jmwh.12934. Accessed August 23,
2019.
21. Saldanha, N. Use of short acting reversible contraception in adolescents: The pill, patch, ring,
and emergency contraception. Curr Probl Pediatr. 2018; 48(2), 333-344.
https://doi.org/10.1016/j.cppeds.2018.11.003. Accessed July 28, 2019.
22. Guzzo, KB, Hayford, SR. Adolescent reproductive and contraceptive beliefs and attitudes
and adult contraceptive behavior. Matern Child Health J. 2018; 22(1), 32-40.
https://link.springer.com/article/10.1007%2Fs10995-017-2351-7. Accessed August 23, 2019.
12
Table 1. US Medical Eligibility Criteria for Contraceptive Use Classification Categories
1
A condition for which there is no restriction for the use of the contraceptive method.
2
A condition for which the advantages of using the method generally outweigh the
theoretical or proven risks.
3
A condition for which the theoretical or proven risks usually outweigh the advantages of
using the method.
4
A condition that represents an unacceptable health risk if the contraceptive method is
used.
Source: Centers for Disease Control and Prevention.
15
13
Table 2. Treatment of Uncomplicated N gonorrhoeae and C trachomatis Infections
Medication
Dose
Route
Frequency,
per day
Duration,
day
Recommended Regimens for C trachomatis
Azithromycin (Zithromax)
1 g
Oral
1
1
or
Doxycycline (Doryx)
100 mg
Oral
2
7
Alternative Regimens for C trachomatis
Erythromycin base (Ery-
Tab)
500 mg
Oral
4
7
or
Erythromycin ethyl
succinate (EES 400)
800 mg
Oral
4
7
or
Levofloxacin (Levaquin)
500 mg
Oral
1
7
or
Ofloxacin (Floxin)
300 mg
Oral
2
7
Recommended Regimen for N gonorrhoeae
Ceftriaxone (Rocephin)
250 mg
IM
1
1
plus
Azithromycin (Zithromax)
1 g
Oral
1
1
Alternative Regimen for N gonorrhoeae: If ceftriaxone is not available
Cefixime (Suprax)
400 mg
Oral
1
1
plus
Azithromycin (Zithromax)
1 g
Oral
1
1
Source: Centers for Disease Control and Prevention.
1
14
Table 3. Treatment of Mild to Moderately Severe Pelvic Inflammatory Disease
Medication
Dose
Route
Frequency,
per day
Duration,
day
Recommended Intramuscular/Oral Regimens
Ceftriaxone (Rocephin)
250 mg
IM
1
1
plus
Doxycycline (Doryx)
100 mg
Oral
2
14
with* or without
Metronidazole (Flagyl)
500 mg
Oral
2
14
or
Cefoxitin (Mefoxin)
2 g
IM
1
1
and
Probenecid (Probalan)
1 g
Oral
1
1
plus
Doxycycline (Doryx)
100 mg
Oral
2
14
with* or without
Metronidazole (Flagyl)
500 mg
Oral
2
14
or
Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime)
plus
Doxycycline (Doryx)
100 mg
Oral
2
14
with* or without
Metronidazole (Flagyl)
500 mg
Oral
2
14
*The recommended third-generation cephalosporins are limited in the coverage of anaerobes.
Therefore, until it is known that extended anaerobic coverage is not important for treatment of
acute pelvic inflammatory disease, the addition of metronidazole to treatment regimens with
third-generation cephalosporins should be considered.
Source: Centers for Disease Control and Prevention.
1
15
Figure 1. Management of Pelvic Inflammatory Disease in Intrauterine Device Users
*Treat according to CDC’s STD Treatment Guidelines (available at
https://www.cdc.gov/std/treatment).
Abbreviations: IUD, intrauterine device; PID, pelvic inflammatory disease.
Source: Adapted from Center for Disease Control and Prevention.
3
