Diaa M. El-Mowafi - Zagagig University, Egypt

Chlamydia trachomatis in women with intermenstrual bleeding using different methods of contraception

Diaa M. El-Mowafi, MD¹ and Umnia A. El-Hendy, MD²
Obstetrics and Gynecology¹ and Microbiology & Immunology² Departments,
Benha Faculty of Medicine, Egypt

Abstract

Intermenstrual bleeding is a troublesome complaint in women using the hormonal methods of contraception or the intrauterine contraceptive devices. This type of bleeding was traditionally attributed to the lack of sufficient hormonal support in case of hormonal contraceptions or to the local mechanical irritation in case of IUCDs.

We postulated that endometritis may be the cause behind this bleeding and we enrolled 140 women in this study. They had been divided into 7 groups each consists of 20 women. The first group was women who are using combined contraceptive pills (COCs) for more than 3 months without complaining of intermenstrual bleeding. The second group was women who are using the same COC for more than 3 months and having intermenstrual bleeding in the previous 3 cycles at least, for which no probable cause could be detected. The third group was women who are using the progestogen-only pills for more than 3 months without intermenstrual bleeding. The forth group was women who are using the same mini-pills for more than 3 months and were having intermenstrual bleeding in the previous 3 cycles at least, for which a probable cause could not be demonstrated. The fifth group was women who are using copper IUDs for more than 3 months without intermenstrual bleeding. The sixth group was women who are using copper IUDs for more than 3 months and complaining of intermenstrual bleeding in the previous 3 cycles at least, for which a probable cause could not be detected. The last group was women who are not using a method of contraception in the previous 3 months considered as a control group. Direct detection of C. trachomatis antigen in both endocervical and endometrial samples from the studied population was done by direct immunoflourescence (DIMF) test.

Our results showed an increase incidence of C. trachomatis in the IUCDs users than it in COCs users, and both had higher incidence than it in mini-pills users without intermenstrual bleeding. Patients with intermenstrual bleeding had higher incidence of C. trachomatis than the patients using the same method of contraception without intermenstrual bleeding. This incidence was higher in IUCDs users than COCs users and both were higher than mini-pills users.

We concluded that C. trachomatis can be the cause of intermenstrual bleeding in women using COCs, mini-pills or IUCDs.

Introduction

Intermenstrual spotting is a troublesome complaint in patients using oral hormonal contraceptions either combined or progestogen-only pills. Traditionally, this "breakthrough bleeding" has been attributed to failure of synthetic hormones to provide adequate support for endometrial integrity. Most pamphlets in birth control pills reassure the patient that this is a benign self-limited phenomenon, usually occur in the first few months of use and it can be managed by increasing the dose of the pills (Hatcher et al., 1989). In the first year after insertion, between 5% to 15%of women will have their IUDs removed because of bleeding or spotting. In most cases, it was attributed to mechanical irritation of the endometrium. What is poorly perceived in the literature is that intermenstrual spotting in patients using these methods of contraception for few months without bleeding complication is a possible sign of chronic endometritis. The purpose of this article is to compare the prevalence of chlamydial antigen among these groups of contraceptive users with and without intermenstrual spotting or bleeding.

Patients, Materials, and Methods

Patients

One hundred and forty women attending the Family Planning or the Gynecology clinic in Benha University Hospitals were enrolled in this study. Their age ranged between 17-40 years and divided into 7 groups:

• Group 1: 20 women who are using combined oral contraception (COC) (Microvlar, Schering, Germany or Nordette, Wieth, NY, USA) for more than 3 months without complaining of intermenstrual bleeding.
• Group 2: 20 women who are using the same COC for more than 3 months and having intermenstrual bleeding in the previous 3 cycles at least, for which no probable cause could be detected.
• Group 3: 20 women who are using the progestogen-only pills (mini-pills) (Mýicrolut, Schering, Germany) for more than 3 months without intermenstrual bleeding.
• Group 4: 20 women who are using the same mini-pills for more than 3 months and were having intermenstrual bleeding in the previous 3 cycles at least, for which a probable cause could not be demonstrated.
• Group 5: 20 women who are using copper IUDs for more than 3 months without intermenstrual bleeding.
• Group 6: 20 women who are using copper IUDs for more than 3 months and complaining of intermenstrual bleeding in the previous 3 cycles at least, for which a probable cause could not be detected.
• Group 7: 20 women who are not using a method of contraception in the previous 3 months considered as a control group.

All groups were subjected to the following:

• Complete history taking including age, parity, marital status, social class, smoking, previous genital tract infection, and hormonal or other treatment in the previous 3 months.
• In groups 2, 4, 6 who complained of intermenstrual bleeding, probable causes as irregular use, myomas, polyps, complications of pregnancy, and erosive cervicitis were excluded.
• A cytobruch was used to obtain the endocervical scraping for chlamydia testing. Endometrial suction curette as Novak's curette was used to obtain the office endometrial samples.
• Direct detection of C. trachomatis antigen in both endocervical and endometrial samples by direct immunoflourescence (DIMF) test. Patho DX, C. trachomatis direct specimen kit (DPC Diagnostic Products Corporation, USA) was used.

Specimen collection and fixation

Dry sterile Casco's speculum was introduced into the vagina to visualize the cervix; any mucus or discharge was removed from the ectocervix by sterile cotton swab. Endocervical specimens were obtained by using sterile cytobruch which inserted about 5-10 seconds using enough pressure to obtain cells from all surfaces of the canal. The swab is then removed without touching the vaginal walls. Endometrial specimens were obtained by using endometrial suction curette.

The swabs were firmly rolled each on an enumerated well of a teflon slides and were allowed to dry in air (5-10 min). The slide was flooded with 0.5 ml methanol and allowed to evaporate. The slides were stored at -20° C and processed with 7 days.

The staining procedure was carried out according to the instructions of the used kit. All components of the kit and specimens should be at room temperature before staining. The reagents were thoroughly mixed before use by gentle swirling the vial.

1. One drop of chlamydia direct reagent was added to each fixed specimen.
2. The slides were incubated for 15 min. at room temperature in huminified chamber.
3. After incubation period, the slides were thoroughly rinsed by agitating them for 10-15 sec. In a beaker or coplin jar filled with deionized or distilled water. They were gently shacked off for removal of excess water and allowed to air-dry completely.
4. One drop of mounting fluid was added to the well, covered by cover slip, and examined by using a fluorescent microscope 40X or 50X objective and 100X oil objective lenses.
5. In positive cases the elementary bodies fluoresce apple green against a background of red counterstained cells (Starry sky appearance)

Results

All our cases and control women were married and have one sexual partner and non-smokers

Table (1): Comparison of the study population

Table (2): C. trachomatis infection in woman using COCs with and without bleeding compared to the control group

X2 = 17.33
P > 0.001

There was increase in the incidence of chlamydia infection in the group using combined oral contraceptive with bleeding compared to the group using the same type of pills without bleeding and the difference was significant. Infection in both groups was significantly higher than the control group.

Table (3): C. trachomatis infection in woman using minipills with and without intermenstrual bleeding compared to the control group

Chlamydia Detection	Minipills without bleeding		Minipills with bleeding		Control		Total
	No	%	No	%	No	%	No	%
Chlamydia +ve	2	10%	5	25%	1	5%	8	13%
Chlamydia -ve	18	90%	15	75%	19	95%	52	87%
Total	20	100%	20	100%	20	100%

X2 = 3.74
P < 0.05

Chlamydia trachomatis infection was detected in 5 women (25%) out of 20 using minipills with intermenstrual bleeding as compared with 2 women (10%) out of 20 using the same type of pills but without bleeding that means increase incidence of infection although the difference was not statistically significant. Both groups also showed increased infection compared to 1 woman out of 20 (5%) infected in the control group.

Table (4): C. trachomatis infection in woman using copper IUCDs with and without intermenstrual bleeding compared to the control group

Chlamydia Detection	IUCDs without bleeding		IUCDs with bleeding		Control		Total
	No	%	No	%	No	%	No	%
Chlamydia +ve	5	20%	11	55%	1	5%	17	28%
Chlamydia -ve	15	80%	9	45%	19	95%	43	71%
Total	20	100%	20	100%	20	100%

X2 = 21.33
P > 0.001

The incidence of chlamydia infection in women using IUCDs with intermenstrual bleeding was significantly higher than that in women using the same IUCDs without intermenstrual bleeding and that in the control group.

Table (5): C. trachomatis infection in woman using different methods of contraception COCs, minipills and IUCDs with no intermenstrual bleeding

Chlamydia Detection	COCs		Minipills		IUCDs		Total
	No	%	No	%	No	%	No	%
Chlamydia +ve	4	20	2	10	5	25	11	18
Chlamydia -ve	16	80	18	90	15	75	49	82
Total	20	100	20	100	20	100	60	100

X2 = 1.55
P > 0.05

The incidence of chlamydial infection in women using IUCDs was 5(25%) in 20 women, compared to 4 women (20%) from 20 using COCs, compared to 2 patients (10%) in 20 women using minipills the difference was not statistically significant.

Table (6): C. trachomatis infection in women using different methods of contraception COCs, minipills and IUCDs with intermenstrual bleeding

Chlamydia Detection	COCs		Minipills*		IUCDs*		Total
	No.	%	No.	%	No.	%	No.	%
Chlamydia +ve	9	45	5	25	11	55	25	12
Chlamydia -ve	11	55	15	75	9	45	35	58
Total	20	100	20	100	20	100	60	100

X2 = 3.84
P > 0.05

* Z test in between = 2.03, p< 0.05

Using Z test, it was found that the incidence of the chlamydial infection in the group using IUCDs and complaining of intermenstrual bleeding was significantly higher than that in women using minipills with intermenstrual bleeding.

Discussion

The cervix is a prime target of the chlamydia (Faro, 1991). Approximately 30-40% of endocervical infection spread to contiguous endometrium (MC Gregor and French, 1991). Intermenstrual uterine bleeding and pelvic pain usually accompany endometritis and significantly correlates with the presence of C. trachomatis in the cervix (Paavonen et al., 1985).

The effect of various contraceptive methods on C. trachomatis infection was examined in 158 women with a mean age of 26-9 years divided into 3 groups: group I, consisting of 30 married women, using IUDs. Group II, comprising of 57 women using oral contraceptives. Group III consisting of 71 women, using other contraceptive methods. Antibodies to C. trachomatis were examined by indirect immunoperoxidase assay with a commercial Kit. It was found that the incidence of C. trachomatis infection was not different in the 3 groups under study (Blum et al., 1988).

C. trachomatis growth can be inhibited in cultured human endometrial cells by copper ions at concentrations known to be released by the copper IUDs. Although the mechanism of inhibition is not known, the continuous presence of copper ion during and after adherence appeared to be necessary for maximal effect.

If such inhibition occurs in vivo, it is possible that copper ion released from copper containing IUDs may partially protect against chlamydial infection (Kleinman et al., 1989). In a contradictory opinion, Faro (1991) reported that the use of an IUD is a risk factor for acquiring C. trachomatis infection, endometritis and salpingitis.

In our study, the incidence of chlamydial infection was statistically higher in IUCDs and COCs users with intermenstrual bleeding than those using the same methods but without bleeding and both were higher than it in women using mini-pills (P> 0.05 Z test).

Oral contraceptives increase cervical ectropion and so theoretically facilitate detection of chlamydia because of more efficient specimen collection (Washington et al., 1985).

Oral contraception, aging, cervical infection, smoking and douching have effect on cervical ectopia that may influence the acquisition and transmission effects of sexually transmitted agents. Ectopia is associated with young age, oral contraception and cervical infection. In women without cervical infection, odema and erythema of the zone of ectopia are associated with oral contraception (Critchlon et al., 1995).

Although oral contraceptives are a reliable contraceptive method, they have limited anti-STD properties and their relationship with STDs remains unclear. Various mechanisms explain a protective role of COCs against STDs; however, in no way can COCs be considered to a safe anti-STD contraceptive method, when compared to specific barrier methods, which provide both contraception and anti-STD protection. Where 10.3% of COCs users presented a prevalence of C. trachomatis when compared to 0% infection rates found among condom users (Creatsas, 1997).

Crowley and associates in 1997 revealed that ectropion and age were the stronger determinates of C. trachomatis detection and not oral contraceptive use.

In this study, we found that the incidence of C. trachomatis infection is less in COCs compared to the IUCDs users and cantrol group and the incidence of C. trachomatis infection is higher in COCs users with intermenstrual bleeding than those with no bleeding. Lastly, we revealed that infection with C. trachomatis is less in women using minipills than users of combined pills. This low infection rate in minipills may be explained by the thick cervical mucus (cervical plug) formed by the minipills, which may act as a barrier for sperms and infection.

Our results as regard the COCs users are coincide with that of Krettek et al., 1993 who noticed that 29.2% of women who are taking COCs for more than 3 months and experiencing bleeding had positive tests for C. trachomatis infection, compared to 10.7% who were also on COCs without intermenstrual spotting and 61% who were screened for infection before initiation of contraception.

The DIMF kit used in this study is specific for the major outer membrane proteins (MOMP) of both the elementary body and reticulate body of C. trachomatis and will detect all the 15 known servers of this organism. Thomas et al., 1984 reported that the DIMF test is more sensitive than other cytological means for diagnosis of chlamydial infection as it detects eight folds higher inclusion count than the staining with iodine. It is highly more sensitive, in the term of number of inclusions, than isolation of chlamydia in the conventional culture method. The cost of DIMF testis dramatically less than the culture method. The omajor advantage of DIMF over culture is the elimination of the problems of storage and transport of specimens under vigorous conditions needed maintain viability.

Hammerschlag et al., (1997) reported that non-culture tests including enzyme immunoassays and direct fluorescent antibody tests have been shown to perform well for diagnosis of chlamydial infection with sensitivity and specificity > or 90% . They also compared between a new commercially available polymerase chain reaction (PCR) assay with culture for detection of C. trachomatis in nasopharyngeal specimen from infant, they found that the PCR was more sensitive than culture for nasopharyngeal specimens.

Our results concluded that the incidence of C. trachomatis infection were more in COCs and IUCDs with intermenstrual bleeding than it in women using the same methods of contraception without bleeding.

The incidence is less in mini-pills users than that using combined pills or IUCDs. So, we recommend to examine users of contraceptive methods (whether pills or IUCDs) who have intermenstrual spotting for C. trachomatis infection in the cervix and endometrium since it is considered as a possible sign of chronic endometritis and not due to failure of synthetic steroids. And also we can consider occurrence of break through bleeding is an additive marker for potential chlamydial infection.

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