Risk-based screening for STI prior to IUD insertion highly sensitive

1. Risk-based screening for chlamydia and gonorrhea prior to intrauterine device insertion was more sensitive than age or partner-based screening.

Evidence Rating Level: 1 (Excellent) 

Study Rundown: Intrauterine devices (IUDs) are some of the most effective forms of birth control, with a failure rate of less than one percent. Despite consistent safety data, some practitioners remain concerned about the risk of pelvic inflammatory disease (PID) after IUD placement. While low, risk of PID does increase slightly during the first 20 days after insertion (1.6 per 1000 women-years). Active infection with chlamydia or gonorrhea at the time of IUD placement increases the risk of PID, such that screening for sexually transmitted infections (STIs) at the time of IUD insertion is common practice. Screening recommendations have been issued by various medical organizations, but currently no standard practice exists. The CDC recommends screening women with at least 1 of 5 risk factors (≤25 years old, new or multiple sexual partners, inconsistent condom use, STI history, and exchanging sex for money, drugs, food or shelter), while The American College of Obstetricians and Gynecologists (ACOG), simply says “high risk” women should be screened. In this study, researchers preformed a secondary analysis of a large prospective cohort study to determine which of 3 screening methods would be the most sensitive for Chlamydia and Gonorrhea prior to IUD insertion.

Findings demonstrated that the risk-based screening strategy, which tested any woman who was ≤25 years old, had multiple sexual partners, reported inconsistent condom use, and/or had a history of a prior STI, was more sensitive than age or age/partner-based screening. A major strength of this study was the large, diverse cohort. Condom use was self-reported, which was a potential limitation as people often over-report condom use. Future studies looking at rates of PID following the implementation of various screening criteria would further clarify the strategy for STI screening prior to IUD insertion.

Click to read the study in Contraception

Relevant Reading: Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review.

In-Depth [prospective cohort]: This secondary analysis of the Contraceptive CHOICE Project, a large prospective cohort study, assessed the sensitivity, specificity, negative and positive predictive values for 3 screening strategies for C. trachomatis and N. gonorrhoeae prior to IUD insertion: 1) age-based (age ≤25), 2) age/partner-based (age ≤25 and/or multiple sexual partners) and 3) risk-based (age ≤25, multiple sexual partners, inconsistent condom use, and/or history of STI).

Among women who chose an IUD at baseline (n = 5087), 140 (2.8%) tested positive for C. trachomatis, 16 (0.3%) for N. gonorrhoeae, and 6 (0.1%) for both at the time of insertion. Risk-based screening had a higher sensitivity (99.3%) than both age-based (80.7%) and age/partner-based (84.7%) screening. If risk-based screening had been implemented at the start of the trial, only one woman with a chlamydia or gonorrhea infection (0.7%) would not have been screened, compared to 29 (19.3%) and 23 (15.3%) for age-based and age/partner-based screening respectively.

Image: PD

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