Pelvic inflammatory disease
Encyclopedia
Pelvic inflammatory disease (or disorder) (PID) is a generic term for inflammation
of the uterus
, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions
to nearby tissues and organs. This may lead to infections. PID is a vague term and can refer to viral, fungal, parasitic, though most often bacterial infections. PID should be classified by affected organs, the stage of the infection, and the organism(s) causing it. Although an STI is often the cause, many other routes are possible, including lymphatic, postpartum, postabortal (either miscarriage or abortion) or intrauterine device (IUD)
related, and hematogenous
spread. Two thirds of patients with laparoscopic evidence of previous PID were not aware they had PID.
, more than 750,000 women are affected by PID each year, and the rate is highest with teenagers and first time mothers. PID causes over 100,000 women to become infertile in the US each year. N. gonorrhoea
is isolated in 40–60% of women with acute salpingitis
. C. trachomatis
is estimated to be the cause in about 60% of cases of salpingitis, which may lead to PID. However, not all PID is caused solely by STIs; organisms that are considered normal vaginal flora
can be involved, and individual cases of PID can be due to either a single organism or a co-infection of many different species. 10% of women in one study had asymptomatic Chlamydia trachomatis
infection and 65% had asymptomatic infection with Neisseria gonorrhoeae. It was noted in one study that 10–40% of untreated women with N. gonorrhoea develop PID and 20–40% of women infected with C. trachomitis developed PID.
, cervical
motion tenderness, lower abdominal pain
, new or different discharge, painful intercourse
, or irregular menstrual
bleeding may be noted. It is important to note that even asymptomatic PID can and does cause serious harm. Laparoscopic identification is helpful in diagnosing tubal disease, 65–90% positive predictive value
in patients with presumed PID. Regular Sexually Transmitted Infection (STI) testing is important for prevention. Treatment is usually started empirical
ly because of the serious complications that may result from delayed treatment. Definitive criteria include: histopathologic evidence of endometritis
, thickened filled fallopian tubes, or laparoscopic findings. Gram-stain/smear becomes important in identification of rare and possibly more serious organisms.
, ectopic pregnancy
, septic abortion
, hemorrhagic or ruptured ovarian cysts or tumors, twisted ovarian cyst, degeneration of a myoma
, and acute enteritis
must be considered. Pelvic inflammatory disease is more likely to occur when there is a history of pelvic inflammatory disease, recent sexual contact, recent onset of menses, or an IUD in place or if the partner has a sexually transmitted infection.
Acute pelvic inflammatory disease is highly unlikely when recent intercourse has not taken place or an IUD is not being used. A sensitive serum pregnancy test should be obtained to rule out ectopic pregnancy. Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix).
Pelvic and vaginal ultrasounds are helpful in the differential diagnosis of ectopic pregnancy of over six weeks. Laparoscopy is often utilized to diagnose pelvic inflammatory disease, and it is imperative if the diagnosis is not certain or if the patient has not responded to antibiotic therapy after 48 hours.
No single test has adequate sensitivity and specificity to diagnose pelvic inflammatory disease. A large multisite U.S. study found that cervical motion tenderness as a minimum clinical criterion increases the sensitivity of the CDC
diagnostic criteria from 83% to 95%. However, even the modified 2002 CDC criteria does not identify women with subclinical disease.
. Since early gonococcal infection may be asymptomatic, regular screening of individuals at risk for common agents (history of multiple partners, history of any unprotected sex, or people with symptoms) or because of certain procedures (post pelvic operation, postpartum, miscarriage
or
abortion
). Prevention is also very important in maintaining viable reproduction capabilities.
If the initial infection is mostly in the lower tract, after treatment the person may have few difficulties. If the infection is in the fallopian tubes or ovaries, more serious complications are more likely to occur.
, which can later cause serious complications, including chronic pelvic pain, infertility
, ectopic pregnancy
(the leading cause of pregnancy-related deaths in adult females), and other dangerous complications of pregnancy. Occasionally, the infection can spread to in the peritoneum
causing inflammation and the formation of scar tissue on the external surface of the liver (Fitz-Hugh-Curtis syndrome
). Multiple infections and infections that are treated later are more likely to result in complications.
Fertility may be restored in women affected by PID. Traditionally tuboplastic
surgery was the main approach to correct tubal obstruction or adhesion formation, however success rates tended to be very limited. In vitro fertilization (IVF) has been used to bypass tubal problems and has become the main treatment for patients who want to become pregnant.
therapy. If the patient has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment. Drugs should also be given orally and/or intravenously to the patient while in the hospital to begin treatment immediately, and to increase the effectiveness of antibiotic treatment. Hospitalization may be necessary if the patient has Tubo-ovarian abscesses; is very ill, immunodeficient, pregnant, or incompetent; or because a life-threatening condition cannot be ruled out. Treating partners for STIs is a very important part of treatment and prevention. Anyone with PID and partners of patients with PID since six months prior to diagnosis should be treated to prevent reinfection. Psychotherapy is highly recommended to women diagnosed with PID as the fear of redeveloping the disease after being cured may exist. It is important for a patient to communicate any issues and/or uncertainties they may have to a doctor, especially a specialist such as a gynecologist, and in doing so, to seek follow-up care.
A systematic review of the literature related to PID treatment was performed prior to the 2006 CDC
sexually transmitted infections treatment guidelines. Strong evidence suggests that neither site nor route of antibiotic administration affects the short or long-term major outcome of women with mild or moderate disease. Data on women with severe disease was inadequate to influence the results of the study.
Regimens include cefoxitin
or cefotetan
plus doxycycline
, clindamycin
plus gentamicin
, ampicillin
and sulbactam
plus doxycycline
, and ceftriaxone
or cefoxitin
plus doxycycline
.
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
of the uterus
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions
Adhesion (medicine)
Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connect tissues not normally connected.-Pathophysiology:...
to nearby tissues and organs. This may lead to infections. PID is a vague term and can refer to viral, fungal, parasitic, though most often bacterial infections. PID should be classified by affected organs, the stage of the infection, and the organism(s) causing it. Although an STI is often the cause, many other routes are possible, including lymphatic, postpartum, postabortal (either miscarriage or abortion) or intrauterine device (IUD)
Intrauterine device
A copper IUD is a type of intrauterine device. Most IUDs have a plastic T- or U-shaped frame which is wrapped in copper wire, with the exception of Gynefix, which is a plastic string with several copper beads, affixed to the fundus of the uterus...
related, and hematogenous
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
spread. Two thirds of patients with laparoscopic evidence of previous PID were not aware they had PID.
Epidemiology
In the United StatesUnited States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, more than 750,000 women are affected by PID each year, and the rate is highest with teenagers and first time mothers. PID causes over 100,000 women to become infertile in the US each year. N. gonorrhoea
Gonorrhea
Gonorrhea is a common sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. The usual symptoms in men are burning with urination and penile discharge. Women, on the other hand, are asymptomatic half the time or have vaginal discharge and pelvic pain...
is isolated in 40–60% of women with acute salpingitis
Salpingitis
Salpingitis is an infection and inflammation in the fallopian tubes. It is often used synonymously with Pelvic inflammatory disease , although PID lacks an accurate definition and can refer to several diseases of the female upper genital tract, such as endometritis, oophoritis, myometritis,...
. C. trachomatis
Chlamydia (bacterium)
Chlamydia is a genus of bacteria that are obligate intracellular parasites. Chlamydia infections are the most common bacterial sexually transmitted infections in humans and are the leading cause of infectious blindness worldwide....
is estimated to be the cause in about 60% of cases of salpingitis, which may lead to PID. However, not all PID is caused solely by STIs; organisms that are considered normal vaginal flora
Vaginal flora
The bacteria that colonize the vagina, collectively referred to as the vaginal microbiome, were discovered by the German gynecologist Albert Döderlein in 1892. The amount and type of bacteria present have significant implications for a woman's overall health...
can be involved, and individual cases of PID can be due to either a single organism or a co-infection of many different species. 10% of women in one study had asymptomatic Chlamydia trachomatis
Chlamydia trachomatis
Chlamydia trachomatis, an obligate intracellular human pathogen, is one of three bacterial species in the genus Chlamydia. C. trachomatis is a Gram-negative bacteria, therefore its cell wall components retain the counter-stain safranin and appear pink under a light microscope.The inclusion bodies...
infection and 65% had asymptomatic infection with Neisseria gonorrhoeae. It was noted in one study that 10–40% of untreated women with N. gonorrhoea develop PID and 20–40% of women infected with C. trachomitis developed PID.
Diagnosis
Symptoms in PID range from subclinical (asymptomatic) to severe. If there are symptoms, then feverFever
Fever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...
, cervical
Cervix
The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall...
motion tenderness, lower abdominal pain
Abdominal pain
Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem...
, new or different discharge, painful intercourse
Dyspareunia
Dyspareunia is painful sexual intercourse, due to medical or psychological causes. The symptom is reported almost exclusively by women, although the problem can also occur in men. The causes are often reversible, even when long-standing, but self-perpetuating pain is a factor after the original...
, or irregular menstrual
Menstrual cycle
The menstrual cycle is the scientific term for the physiological changes that can occur in fertile women for the purpose of sexual reproduction. This article focuses on the human menstrual cycle....
bleeding may be noted. It is important to note that even asymptomatic PID can and does cause serious harm. Laparoscopic identification is helpful in diagnosing tubal disease, 65–90% positive predictive value
Positive predictive value
In statistics and diagnostic testing, the positive predictive value, or precision rate is the proportion of subjects with positive test results who are correctly diagnosed. It is a critical measure of the performance of a diagnostic method, as it reflects the probability that a positive test...
in patients with presumed PID. Regular Sexually Transmitted Infection (STI) testing is important for prevention. Treatment is usually started empirical
Empirical
The word empirical denotes information gained by means of observation or experimentation. Empirical data are data produced by an experiment or observation....
ly because of the serious complications that may result from delayed treatment. Definitive criteria include: histopathologic evidence of endometritis
Endometritis
Endometritis refers to inflammation of the endometrium, the inner lining of the uterus. Pathologists have traditionally classified endometritis as either acute or chronic: acute endometritis is characterized by the presence of microabscesses or neutrophils within the endometrial glands, while...
, thickened filled fallopian tubes, or laparoscopic findings. Gram-stain/smear becomes important in identification of rare and possibly more serious organisms.
Differential diagnosis
AppendicitisAppendicitis
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to...
, ectopic pregnancy
Ectopic pregnancy
An ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication...
, septic abortion
Septic abortion
A septic abortion or septic miscarriage is a form of miscarriage that is associated with a serious uterine infection. The infection carries risk of spreading infection to other parts of the body and cause septicaemia, a grave risk to the life of the woman.-Causes:A septic abortion can occur when...
, hemorrhagic or ruptured ovarian cysts or tumors, twisted ovarian cyst, degeneration of a myoma
Myoma
Myoma is a kind of mesenchymal tumor.-Classification:They are of two types.* The leiomyoma occurs in the skin or gut but the common form is the uterine fibroid.* Rhabdomyomas are rare tumors of muscles, they occur in childhood and often become malignant....
, and acute enteritis
Enteritis
In medicine, enteritis, from Greek words enteron and suffix -itis , refers to inflammation of the small intestine. It is most commonly caused by the ingestion of substances contaminated with pathogenic microorganisms. Symptoms include abdominal pain, cramping, diarrhea, dehydration and fever...
must be considered. Pelvic inflammatory disease is more likely to occur when there is a history of pelvic inflammatory disease, recent sexual contact, recent onset of menses, or an IUD in place or if the partner has a sexually transmitted infection.
Acute pelvic inflammatory disease is highly unlikely when recent intercourse has not taken place or an IUD is not being used. A sensitive serum pregnancy test should be obtained to rule out ectopic pregnancy. Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix).
Pelvic and vaginal ultrasounds are helpful in the differential diagnosis of ectopic pregnancy of over six weeks. Laparoscopy is often utilized to diagnose pelvic inflammatory disease, and it is imperative if the diagnosis is not certain or if the patient has not responded to antibiotic therapy after 48 hours.
No single test has adequate sensitivity and specificity to diagnose pelvic inflammatory disease. A large multisite U.S. study found that cervical motion tenderness as a minimum clinical criterion increases the sensitivity of the CDC
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention are a United States federal agency under the Department of Health and Human Services headquartered in Druid Hills, unincorporated DeKalb County, Georgia, in Greater Atlanta...
diagnostic criteria from 83% to 95%. However, even the modified 2002 CDC criteria does not identify women with subclinical disease.
Prognosis
Although the PID infection itself may be cured, effects of the infection may be permanent. This makes early identification by someone who can prescribe appropriate curative treatment very important in the prevention of damage to the reproductive systemReproductive system
The reproductive system or genital system is a system of organs within an organism which work together for the purpose of reproduction. Many non-living substances such as fluids, hormones, and pheromones are also important accessories to the reproductive system. Unlike most organ systems, the sexes...
. Since early gonococcal infection may be asymptomatic, regular screening of individuals at risk for common agents (history of multiple partners, history of any unprotected sex, or people with symptoms) or because of certain procedures (post pelvic operation, postpartum, miscarriage
Miscarriage
Miscarriage or spontaneous abortion is the spontaneous end of a pregnancy at a stage where the embryo or fetus is incapable of surviving independently, generally defined in humans at prior to 20 weeks of gestation...
or
abortion
Abortion
Abortion is defined as the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability. An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely induced...
). Prevention is also very important in maintaining viable reproduction capabilities.
If the initial infection is mostly in the lower tract, after treatment the person may have few difficulties. If the infection is in the fallopian tubes or ovaries, more serious complications are more likely to occur.
Complications
PID can cause scarring inside the reproductive organsReproductive system
The reproductive system or genital system is a system of organs within an organism which work together for the purpose of reproduction. Many non-living substances such as fluids, hormones, and pheromones are also important accessories to the reproductive system. Unlike most organ systems, the sexes...
, which can later cause serious complications, including chronic pelvic pain, infertility
Infertility
Infertility primarily refers to the biological inability of a person to contribute to conception. Infertility may also refer to the state of a woman who is unable to carry a pregnancy to full term...
, ectopic pregnancy
Ectopic pregnancy
An ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication...
(the leading cause of pregnancy-related deaths in adult females), and other dangerous complications of pregnancy. Occasionally, the infection can spread to in the peritoneum
Peritoneum
The peritoneum is the serous membrane that forms the lining of the abdominal cavity or the coelom — it covers most of the intra-abdominal organs — in amniotes and some invertebrates...
causing inflammation and the formation of scar tissue on the external surface of the liver (Fitz-Hugh-Curtis syndrome
Fitz-Hugh-Curtis syndrome
Fitz-Hugh-Curtis syndrome is a rare complication of pelvic inflammatory disease named after the two physicians, Thomas Fitz-Hugh, Jr and Arthur Hale Curtis who first reported this condition in 1934 and 1930 respectively. It involves liver capsule inflammation.-Pathophysiology:Fitz-Hugh-Curtis...
). Multiple infections and infections that are treated later are more likely to result in complications.
Fertility may be restored in women affected by PID. Traditionally tuboplastic
Tuboplasty
A tuboplasty is a surgical operation to correct a fallopian tube obstruction or adhesion, to achieve a pregnancy in women with tubal infertility. Thus, it is a form of assisted reproductive technology.-Techniques:...
surgery was the main approach to correct tubal obstruction or adhesion formation, however success rates tended to be very limited. In vitro fertilization (IVF) has been used to bypass tubal problems and has become the main treatment for patients who want to become pregnant.
Treatment
Treatment depends on the cause and generally involves use of antibioticAntibiotic
An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...
therapy. If the patient has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment. Drugs should also be given orally and/or intravenously to the patient while in the hospital to begin treatment immediately, and to increase the effectiveness of antibiotic treatment. Hospitalization may be necessary if the patient has Tubo-ovarian abscesses; is very ill, immunodeficient, pregnant, or incompetent; or because a life-threatening condition cannot be ruled out. Treating partners for STIs is a very important part of treatment and prevention. Anyone with PID and partners of patients with PID since six months prior to diagnosis should be treated to prevent reinfection. Psychotherapy is highly recommended to women diagnosed with PID as the fear of redeveloping the disease after being cured may exist. It is important for a patient to communicate any issues and/or uncertainties they may have to a doctor, especially a specialist such as a gynecologist, and in doing so, to seek follow-up care.
A systematic review of the literature related to PID treatment was performed prior to the 2006 CDC
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention are a United States federal agency under the Department of Health and Human Services headquartered in Druid Hills, unincorporated DeKalb County, Georgia, in Greater Atlanta...
sexually transmitted infections treatment guidelines. Strong evidence suggests that neither site nor route of antibiotic administration affects the short or long-term major outcome of women with mild or moderate disease. Data on women with severe disease was inadequate to influence the results of the study.
Regimens include cefoxitin
Cefoxitin
Cefoxitin is a cephamycin antibiotic developed by Merck & Co., Inc., often grouped with the second−generation cephalosporins. It is sold under the brand name Mefoxin.- Microbiology :...
or cefotetan
Cefotetan
Cefotetan is an injectable antibiotic of the cephamycin type for prophylaxis and treatment of bacterial infections. It is often grouped together with second-generation cephalosporins and has a similar antibacterial spectrum, but with additional anti-anaerobe coverage.Cefotetan was developed by...
plus doxycycline
Doxycycline
Doxycycline INN is a member of the tetracycline antibiotics group, and is commonly used to treat a variety of infections. Doxycycline is a semisynthetic tetracycline invented and clinically developed in the early 1960s by Pfizer Inc. and marketed under the brand name Vibramycin. Vibramycin...
, clindamycin
Clindamycin
Clindamycin rINN is a lincosamide antibiotic. It is usually used to treat infections with anaerobic bacteria but can also be used to treat some protozoal diseases, such as malaria...
plus gentamicin
Gentamicin
Gentamicin is an aminoglycoside antibiotic, used to treat many types of bacterial infections, particularly those caused by Gram-negative organisms. However, gentamicin is not used for Neisseria gonorrhoeae, Neisseria meningitidis or Legionella pneumophila...
, ampicillin
Ampicillin
Ampicillin is a beta-lactam antibiotic that has been used extensively to treat bacterial infections since 1961. Until the introduction of ampicillin by the British company Beecham, penicillin therapies had only been effective against Gram-positive organisms such as staphylococci and streptococci...
and sulbactam
Sulbactam
Sulbactam is a molecule that is given in combination with beta-lactam antibiotics to inhibit beta-lactamase, an enzyme produced by bacteria that destroys the antibiotics...
plus doxycycline
Doxycycline
Doxycycline INN is a member of the tetracycline antibiotics group, and is commonly used to treat a variety of infections. Doxycycline is a semisynthetic tetracycline invented and clinically developed in the early 1960s by Pfizer Inc. and marketed under the brand name Vibramycin. Vibramycin...
, and ceftriaxone
Ceftriaxone
Ceftriaxone is a third-generation cephalosporin antibiotic. Like other third-generation cephalosporins, it has broad spectrum activity against Gram-positive and Gram-negative bacteria. In most cases, it is considered to be equivalent to cefotaxime in terms of safety and efficacy...
or cefoxitin
Cefoxitin
Cefoxitin is a cephamycin antibiotic developed by Merck & Co., Inc., often grouped with the second−generation cephalosporins. It is sold under the brand name Mefoxin.- Microbiology :...
plus doxycycline
Doxycycline
Doxycycline INN is a member of the tetracycline antibiotics group, and is commonly used to treat a variety of infections. Doxycycline is a semisynthetic tetracycline invented and clinically developed in the early 1960s by Pfizer Inc. and marketed under the brand name Vibramycin. Vibramycin...
.
Prevention
- Risk reduction against sexually transmitted infections through barrier methods such as condoms; see human sexual behaviorHuman sexual behaviorHuman sexual activities or human sexual practices or human sexual behavior refers to the manner in which humans experience and express their sexuality. People engage in a variety of sexual acts from time to time, and for a wide variety of reasons...
for other listings. - Going to the doctor immediately if symptoms of PID, sexually transmitted infections appear, or after learning that a current or former sex partner has, or might have had a sexually transmitted infection.
- Getting regular gynecological (pelvic) exams with STI testing to screen for symptomless PID.
- Discussing sexual history with a trusted physician in order to get properly screened for sexually transmitted diseases.
- Regularly scheduling STI testing with a physician and discussing which tests will be performed that session.
- Getting a STI history from your current partner and insisting they be tested and treated before intercourse.
- Treating partners to prevent reinfection or spreading the infection to other people.
- Diligence in avoiding vaginal activity, particularly intercourse, after the end of a pregnancy (delivery, miscarriage, or abortion) or certain gynecological procedures, to ensure that the cervix closes.
See also
- SalpingitisSalpingitisSalpingitis is an infection and inflammation in the fallopian tubes. It is often used synonymously with Pelvic inflammatory disease , although PID lacks an accurate definition and can refer to several diseases of the female upper genital tract, such as endometritis, oophoritis, myometritis,...
, any inflammation of the fallopian tubes - Tubo-ovarian abscess an abscessAbscessAn abscess is a collection of pus that has accumulated in a cavity formed by the tissue in which the pus resides due to an infectious process or other foreign materials...
of the fallopian tube and ovary - EndometritisEndometritisEndometritis refers to inflammation of the endometrium, the inner lining of the uterus. Pathologists have traditionally classified endometritis as either acute or chronic: acute endometritis is characterized by the presence of microabscesses or neutrophils within the endometrial glands, while...
- Pelvic peritonitisPeritonitisPeritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of...
- Dalkon ShieldDalkon ShieldThe Dalkon Shield was a contraceptive intrauterine device developed by the Dalkon Corporation and marketed by the A.H. Robins Company. The Dalkon Shield was found to cause severe injury to a disproportionately large percentage of its users, which eventually led to numerous lawsuits in which...
— withdrawn from the market in 1975 for PID risk - Bacterial VaginosisBacterial vaginosisBacterial vaginosis or less commonly vaginal bacteriosis is a disease of the vagina caused by bacteria. The U.S. Centers for Disease Control and Prevention states it is not clear what role sexual activity plays in the development. However, it is known that BV is associated with having a new sex...