Upper Genital Tract Infections Following IUD Insertion Are Considered PID
Yes, upper genital tract infections that occur following IUD insertion are classified as pelvic inflammatory disease (PID), as IUD insertion is recognized as a mechanism that facilitates the upward spread of vaginal and cervical bacteria into the upper genital tract. 1
Pathophysiologic Mechanism
The CDC guidelines explicitly identify uterine instrumentation, specifically IUD insertion, as a factor that facilitates upward spread of vaginal and cervical bacteria to the endometrium and fallopian tubes, which is the fundamental pathogenesis of PID. 1
- PID results from direct canalicular spread of organisms from the endocervix to the endometrial and fallopian tube mucosa 1
- IUD insertion mechanically disrupts the cervical barrier, allowing bacteria present in the lower genital tract to ascend 1
- The highest risk period is during and immediately after insertion, when bacterial contamination of the endometrial cavity occurs 2, 3
Clinical Classification and Management
When a woman with an IUD develops upper genital tract infection (endometritis, salpingitis, tubo-ovarian abscess), this is diagnosed and managed as PID, regardless of the insertion being the precipitating event. 1
Current PID with IUD in Place
- The CDC Medical Eligibility Criteria assigns Category 4 (unacceptable health risk) for IUD initiation during current PID 1
- For continuation, the category is 2 (benefits generally outweigh risks), meaning the IUD usually does not need to be removed if the woman wishes to continue using it 1
- Treatment consists of appropriate antibiotics for PID; clinical course does not differ whether the IUD is removed or left in place 1
Microbiology
Upper genital tract infections following IUD insertion involve the same polymicrobial flora as other PID cases:
- Chlamydia trachomatis and Neisseria gonorrhoeae (sexually transmitted) 1
- Anaerobes: Bacteroides, Peptostreptococcus, Peptococcus species 1
- Facultative bacteria: Gardnerella vaginalis, Streptococcus species, E. coli, Haemophilus influenzae 1
- Bacterial vaginosis-associated organisms 1
Important Clinical Caveats
The absolute risk of PID following IUD insertion is low in women without pre-existing STIs, but significantly elevated in women with cervical infection at the time of insertion. 1, 3
- Most IUD-associated PID risk occurs in the first few months after insertion 1, 3
- Women with current purulent cervicitis, chlamydial infection, or gonorrhea should not have an IUD inserted (Category 4) until infection is treated 1
- Prophylactic antibiotics at insertion do not significantly reduce PID risk and are not recommended 2, 3
- Culturing removed IUDs in PID patients is unnecessary, as it does not alter clinical management or outcomes 4, 5
The key distinction is timing, not classification: insertion-related PID typically occurs within the first 20 days post-insertion due to bacterial contamination during the procedure, while later PID is usually related to STI acquisition unrelated to the IUD itself. 3