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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

OPPORTUNISTIC SCREENING FOR CHLAMYDIA TRACHOMATIS INFECTION PRIOR TO INSERTION OF INTRAUTERINE CONTRACEPTIVE DEVICE

LITERATURE REVIEW

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

INTRODUCTION
!he idea for my pro"ect arose at my first #P practice placement follo$ing discussions $ith my colleagues shortly after my attendance at the %amily Planning Course& Current recommendations in '( %amily Planning Clinics is to perform a set of screening s$a)s for se*ually transmitted diseases +,!-s. )efore or at the time of insertion of intrauterine contraceptive device +/'C-.0 $hich usually includes high vaginal and chlamydial s$a)s& !hat practice seemed to correspond to the practice in O)stetric and #ynaecology departments in $hich / $or1ed for the previous 3 years& -uring my first #P registrar placement / too1 particular interest and learned ho$ much contraceptive and 23ell 3oman4 care ta1es place in primary care practice& 5t one of the tutorials / had a chance to discuss issues of $omen6s health0 contraception and screening for ,!-s& %rom that discussion / understood that testing for ,!-s and especially for Chlamydia trachomatis infection only ta1es place $hen a patient is symptomatic or there are clinical suspicions of the condition0 )ut not as a routine prior to /'C-& !hat discussion prompted me to underta1e a short data search in the #P practice / $or1ed in at that time& !hat confirmed that in a 1 year period of all $omen $ho had coils inserted in our #P practice only these $ith clinical symptoms and signs $ere tested for Chlamydia trachomatis infection&

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

/ decided to search the literature to see if there is evidence that testing for chlamydial infection should )e performed prior to /'C- insertion& / find this topic important )ecause the ma"ority of contraceptive care and se*ual health promotion issues are dealt $ith in a primary care setting0 therefore it is important that it is up to date and in accordance $ith most recent evidence )ased research and guidelines&

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

AIMS
%irstly0 / $anted to find out if there is evidence that screening for Chlamydia trachomatis prior to /'C- insertion decreases the ris1 of developing Pelvic /nflammatory -isease +P/-. and its complications& ,econdly0 if such evidence is not clear or does not e*ist / $anted to 1no$ $hat are the important issues around this topic that $ould suggest that such screening is appropriate or inappropriate& !hirdly0 / $ished to e*plore issues related to ris1s of infection at the time and after insertion of /'C-& %inally0 / thought it is important to learn more a)out Chlamydia trachomatis infection and Pelvic /nflammatory -isease itself0 its ris1 factors0 prevalence0 infection spread and complications0 to )etter understand the natural history and dynamic of these conditions&

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

METHOD
/ revie$ed current literature to find if there is evidence that screening for genital infections prior to /'C- insertion decreases the incidence of Chlamydia trachomatis infection and P/-& !his $as performed )y accessing the 8edline and Cochrane data)ases using the 1ey$ords 2Chlamydia !rachomatis40 2Pelvi /nflammatory -isease40 2/ntra 'terine Contraceptive -evices40 4,e*ually !ransmitted -iseases screening4& / $idened my search )y visiting relevant $e)sites including 9ational /nstitute of Clinical :*celence +9/C:.0 ,cottish /ntercollegiate #uidelines 9et$or1 +,/#9.0 PRO-/#Y0 Royal College of O)stetricians and #ynaecologists +RCO#.0 and -rugs and !herapeutics ;ulletin +-!;.& / also revie$ed all guidelines related to ,!-s0 Chlamydia trachomatis0 and /'C- insertion in 9ational :lectronic <ealth =i)rary +9:<=.& /f the a)stract of the article or guideline $as relevant to the researched topic / retrieved the full te*t& / also searched for articles and studies related to the topic to gain more insight and understanding of Chlamydia trachomatis infection to )e a)le to dra$ evidence )ased conclusion regarding screening for this infection prior to /'C- insertion&

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

RESULTS OF FINDINGS
Pelvic /nflammatory -isease is the clinical syndrome implying infection of the upper genital tract caused )y ascent of se*ually transmitted )acteria +mainly Chlamydia trachomatis and 9eisseria gonorrhea. from the vagina and endocervi* to the endometrium and %allopian tu)es +40 >.& /nfective organisms can )e introduced )y se*ual intercourse0 insertion of /'C-0 during hysteroscopy0 endometrial )iopsy0 termination of pregnancy and infertility investigations and treatment +70 >.& Ris1 factors for Chlamydia trachomatis infections include multiple partners0 age less than 70 lo$ leaving school age0 )eing single0 recent change of partner0 ethnic group0 previous se*ually transmitted diseases + 0 30 ?.& Chlamydia trachomatis is one of the most common treata)le0 )acterial se*ually transmitted diseases& /ts prevalence has increased )y 70@ since 1?880 mainly amongst $omen under 7 years of age +3.& /n most $omen Pelvic /nflammatory -isease is asymptomatic0 and up to A0@ have no clinical symptoms or signs +40 >.& /n others symptoms include fever0 malaise0 a)dominal and pelvic pain0 and vaginal discharge& Regardless of the presentation 0@ of $omen $ith P/- develop chronic pelvic pain0 0@ )ecome infertile0 and 10@ of these $ho conceive develop ectopic pregnancy +40 >.& !he pro)lem is regarded as largely underestimated and overloo1ed )y health professionals +11.& One study $as conducted in a surgery in the 3a1efield area0 Yor1shire& !he aim of this study $as to assess the prevalence of Chlamydia trachomatis infection using

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

opportunistic screening +urine sample. in $omen )et$een 13 and 4 years old& >0@ of those targeted chose not to su)mit the sample& /n those $ho su)mitted a sample the prevalence $as nearly 11@ + .& 5 cohort study0 $hich $as conducted in the '( )et$een 1?>8B A4 and involved 1A003 married0 parous $omen )et$een 7B 3? years of age0 found that the rate of P/- $as higher in users of /'C-s than in nonB users& !he dra$)ac1 of this study is that $omen in the control group used other methods of contraception such as oral contraceptives +including progesteronBonly pill. and diaphragms $hich are 1no$n to reduce the transmission and infection rates for ,!-s +>01 .& 5 ;raCilian study $as carried out using a group of 40A $omen $ho $ished to use a coil as a method of contraception& ? of them had symptoms or signs of P/- so /'C- $as not offered& /'C-s $ere not inserted in $omen suspected of having infection& Of these $ho had /'C- inserted0 1? $ere su)seDuently found to have Chlamydia trachomatis infections0 $omen returned $ith symptoms and 1A $ere asymptomatic& %rom this

study it is impossi)le to conclude $hether they had infection prior to the coil insertion0 or if the infection $as introduced at the time of instrumentation0 or if it $as acDuired after$ards& !hese results reinforce the need for careful selection of patients for /'C-s insertion0 thorough counselling for symptoms and need for action should the infection occur +1.&

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

5 national screening program for genital chlamydial infection $as rolled out from 00 +10.& /nitially0 the screening program $ill )e started in 10 sites0 )uilding on successful pilots in Portsmouth and 3irral& !his $ill )e an opportunistic screening program0 $hich $ill mainly target $omen $ho access services such as %amily Planning Clinics& !he design of the program $ill )e guided )y the study currently loo1ing at the rates of infection $ith chlamydia +1.& !he decision to consider a national screening program follo$ed recommendations made )y the Chief 8edical Officer6s :*pert 5dvisory #roup on Chlamydia trachomatis +?.& !he group concluded opportunistic screening for genital chlamydial infection should )e offered to all #enitourinary Clinic attendees0 as there is evidence of consistently high prevalence rates of this infection& 5ll $omen see1ing termination of pregnancy $ould )e screened as there is compelling evidence that the procedure increases the ris1 of infection ascending during the procedure +)oth medical and surgical. to cause pelvic infection& 5ll $omen under 7 years of age and $omen over 7 years of age $ith a ne$ partner or $ho had t$o or more partners in last 1 months $ould )e screened0 )ecause of a study )ased in '( $hich found that if this strategy $as used only 4?@ of $omen $ould )e tested 0 )ut 8A@ of chlamydial infection $ould )e detected +30 ?.& !he :*pert 5dvisory #roup also recommended that $omen undergoing instrumentation of the uterus +$hich includes insertion of /'C-s. should )e considered for screening +30 ?0 10.& !hey emphasise that there is limited evidence suggesting that screening )efore

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

/'C- insertion reduces ris1 of P/- +10.0 and the prevalence of Chlamydia infection in $omen receiving /'C-s is li1ely to )e lo$0 as most of them are multiparous and over 7 years of age +?.& 9evertheless the Royal College O)stetricians and #ynaecologists recommends that all $omen under 37 should )e screened prior to /'C- insertion +10.& !he %amily Planning Clinic association states that it is good practice to screen for infection in all $omen )efore /'C- insertion +8.& !he recent -rugs and !herapeutics ;ulletin article suggests the possi)le plan of action )efore /'C- insertion +>.& !hey postulate that careful and detailed history is ta1en assessing se*ual history0 relevant history of partners0 practices and se*ually transmitted diseases& Chlamydia testing should )e offered to all at ris10 including under 7s0 thoe $ith more than one partner and those $ith a history of se*ually transmitted diseases& 5ppropriate ris1 assessment should identify individuals unli1ely to reDuire such testing& !o minimise the li1elihood of complications it suggests to avoiding inserting the /'Cin any $omen $ith proven or suspected infection +10 A.& /t may ho$ever )e inserted in a $oman in $hom infection has )een successfully treated provided that her +and her partner6s. se*ual practices no longer put her at ris1& Prophylactic anti)iotics are said to )e unli1ely to improve outcomes in $omen $ith lo$ ris1 of se*ually transmitted diseases0 and should not )e used +A.& !he ris1 of infection0 through insertion of the coil0 could )e reduced )y using long lasting devices +7 years.0 and thus reducing the num)er of reBinsertions +>.&

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

5ll $omen receiving /'C-s should )e counselled a)out increased ris1 of Chlamydial infection and development of P/- $ithin 3 $ee1s after insertion as $ell as the possi)ility of ectopic pregnancy and infertility should the P/- develop +40 70 >.& 3omen should also )e told of the symptoms of infection so they could see1 medical advice and treatment early +>0 8.&

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

DISCUSSION
!hough there is no direct research or study $hich e*amines if opportunistic screening for Chlamydial infection prior to /'C- insertion reduces the ris1 of this infection and P/- +10.0 there is a lot of research related to various aspects of Chlamydial infection0 $hich in turn allo$s us to dra$ ne$ conclusions leading to improvement of e*isting practice& !here are studies that prove increased prevalence of Chlamydial infection + .0 recognise that most cases are asymptomatic0 and carry very high rates of complications +4.& !here is evidenceB)ased research $hich esta)lishes ris1 factors for the condition +3.& !here is also proven evidence that any intrauterine instrumentation including /'C- insertion increase the ris1 of Chlamydial infection +7.& On the )asis of this research the Chief 8edical Officer6s :*pert 5dvisory #roup on Chlamydia infection formulated a national screening program $hich includes recommendation for screening prior to /'C- insertion +?.& !hese recommendations are echoed in $idely availa)le national guidelines $hich are pu)lished across the country such as the ,cottish /ntercollegiate #uidelines 9et$or1 +11.0 PRO-/#Y +10.0 9ational :lectronic =i)rary of <ealth0 and -rugs and !herapeutic ;ulletin +>.& /n summary they all recommend that opportunistic screening should )e

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

performed and it should )e proceeded )y appropriate ris1 factor assessment and supported )y adeDuate counselling&

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

CONCLUSIONS
/ )elieve that the topic of screening for Chlamydial infection )efore insertion of the coils is important and relevant to general practice& %or this reason0 as soon as / prepared the findings of my search / presented them at the clinical multidisciplinary meeting in my practice& / understand that my search helped )oth doctors and nurses in the practice to consolidate e*isting 1no$ledge a)out Chlamydial infection& !he presentation lead to discussion and e*change of e*perience )et$een doctors& !he practical issues such as $hich test is )est for screening0 ho$ to counsel patients0 ho$ to organise appointments to )e most time efficient $ere discussed& / )elieve that my presentation and findings $ill lead to an improvement in e*isting practice& /t $ill ma1e it more uniform and consistent0 as all team mem)ers +)oth doctors and practice nurses. are no$ more a$are of the ris1 group for chlamydial infection and $ill use opportunistic screening not only at the time of the coil insertion )ut also in such situations as cervical smear ta1ing0 if it is appropriate& !his literature search $as also very useful to me& /t helped me realise that genital Chlamydial infection0 though asymptomatic in most cases0 has a very high complication rate& /t helped me to learn a)out ris1 factors for contracting this condition and gave me guidance for my o$n practice& /n summary0 it )ecame evident that all $omen coming for insertion of /'C- should )e first of all chec1ed if they )elong to a ris1 group for Chlamydial infection +under 7

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

years old0 $ith more than

partners in the last year0 previous ,!-s0 ne$ partner.& !hey

should also )e as1ed a)out symptoms such as pelvic pain0 and vaginal discharge& /f the patient falls into criterion of high ris1 for Chlamydial infection the screening test should )e offered0 and the /'C- inserted after the test results come )ac1 negative& /f the Chlamydial test comes )ac1 positive0 the $oman should )e treated and advised regarding contact tracing& 3hen repeated tests come )ac1 negative0 the /'C- could )e inserted& 5ll $omen in the lo$ ris1 group +over 7 years of age $ith one partner0 in long term relationship0 no previous ,!-s. can have the coil inserted $ithout screening for Chlamydia trachomatis infection& 5ll $omen should )e told a)out a small ris1 of infection follo$ing the procedure and $arned that if symptoms of malaise0 pelvic pain and vaginal discharge develop they should see1 medical attention& #eneral Practitioners are reDuired to deliver Duality care to their patients and to practice evidence )ased medicine& Currently a large part of contraceptive care and service ta1es place in primary care setting& #enerally0 /'C-s are a convenient0 ine*pensive0 relia)le form of contraception& !he insertion of the coil reDuires0 though training is not difficult and carries only a small rate of complications& /ncorporating the opportunistic screening )efore coil insertion into current practice $ill allo$ #eneral Practitioners not only to decrease their patient mor)idity and avoid complications0 )ut it $ill also contri)ute to their patient satisfaction&

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

LITERATURE
1& !he ris1 of inadvertent intrauterine device insertion in $omen carries of endocervical Chlamydia trachomatis& %audas 50 !elles :0 Cristofoletti 8=0 %audes -0 Castro ,0 <ardy :& -epatamento de #inecologia e O)stetricia0 %aculdade de Ciencias 8edicas0 +'9/C58P.0 ;raCil0 Contraception 5ug 1??8E78+ .F107B?& & Chlamydia trachomatisF opportunistic screening in primary care& !o)in C0 5ggarval R0 Clar1e G& at all& Consultant in genitourinary medicine0 3a1efield& ;r& G& #en& Pract& 71 +4>8.F 7>7B7>>0 Gul 001& 3& :ducation and -e)ate H ,creening for genital chlamydial infection& Pimenta G0 Catchpole 80 #ray 80 <op$ood G& at al& Pu)lic <ealth =a)oratory ,ervice Communica)le -isease ,urveillance0 =ondon& ;8G0 3 1 +A >1.F > ?B >310 ,ept 000& 4& Pelvic /nflammatory disease& Ross G& Clinical :vidence0 issue A0 =ondon0 ;8G pu)lishing group Gune 00 & 7& /ntrauterine device and upper genital tract infection& #rimes -50 =ancet0 37>F1013B ?0 000 >& Copper /'-s0 infection and infertility& -rugs and !herapeutic ;ulletin0 Iol 400 9o ?0E>>B>?0 ,ept 00 & A& 5nti)iotic prophyla*is for intrauterine contraceptive device insertion& #rimes -50 ,chulC (%& !he Cochrane =i)rary0 /ssue 30 00 &

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YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of intrauterine contraceptive device

8& /ntrauterine contraceptive devices& ;elfield !& %P5 contraceptive hand)oo1F a guide for family planning and other health professionalsF ?3B 107& %amily Planning 5ssociation& =ondon 1???& ?& ,ummary of conclusions of C8O6s :*pert 5dvisory #roup Report on Chlamydia !rachomatis& -ept& of <ealth0 =ondon 1??8& 10& Prodigy #uidanceB ChlamydiaB genital& =ast revised -ec 00 & 11& 8anagement of genital Chlamydia trachomatis infection& ,cottish /ntercollegiate #uideline 9et$or1& Pu)lication 9o& 4 & :din)urgh& 8arch 000& 1 & Pelvic inflammatory disease and the intrauterine device0 findings in a large cohort study& Iessey 8P at al& ;8G 1?81E 8 F877BA&

3ord countF >14&