Pelvic Inammatory Disease

MARGARET GRADISON, MD, MHS-CL, Duke University Medical Center, Durham, North Carolina

Pelvic inammatory disease is a polymicrobial infection of the upper genital tract. It primarily affects young, sexually active women. The diagnosis is made clinically; no single test or study is sensitive or specic enough for a denitive diagnosis. Pelvic inammatory disease should be suspected in at-risk patients who present with pelvic or lower abdominal pain with no identied etiology, and who have cervical motion, uterine, or adnexal tenderness. Chlamydia trachomatis and Neisseria gonorrhoeae are the most commonly implicated microorganisms; however, other microorganisms may be involved. The spectrum of disease ranges from asymptomatic to life-threatening tubo-ovarian abscess. Patients should be treated empirically, even if they present with few symptoms. Most women can be treated successfully as outpatients with a single dose of a parenteral cephalosporin plus oral doxycycline, with or without oral metronidazole. Delay in treatment may lead to major sequelae, including chronic pelvic pain, ectopic pregnancy, and infertility. Hospitalization and parenteral treatment are recommended if the patient is pregnant, has human immunodeciency virus infection, does not respond to oral medication, or is severely ill. Strategies for preventing pelvic inammatory disease include routine screening for chlamydia and patient education. (Am Fam Physician. 2012;85(8):791-796. Copyright 2012 American Academy of Family Physicians.)
Patient information: A handout on pelvic inammatory disease, written by the author of this article, is provided on page 797.

elvic inammatory disease (PID) is a polymicrobial infection of the upper genital tract that primarily affects young, sexually active women. There are 750,000 cases of PID each year in the United States, mainly in women 15 to 29 years of age.1 This number has remained constant since the early 1990s, after decreasing in the previous decades. Most women are treated in the outpatient setting. The number of hospitalizations has steadily decreased over the past decade.1 The cost of PID is approximately $2,000 per patient, which equals about $1.5 billion annually.2 It is estimated that 80 to 90 percent of women with a genital chlamydial infection and 10 percent with gonorrheal infection are asymptomatic. Approximately 10 to 20 percent of women with chlamydial or gonorrheal infections may develop PID if not treated. Women with PID have a 20 percent chance of developing infertility from tubal scarring, a 9 percent chance of having an ectopic pregnancy, and an 18 percent chance of developing chronic pelvic pain.3,4 In 2010, the Centers for Disease Control and Prevention updated its PID guidelines, which are the basis of this review.5 Pathophysiology The microorganisms that are implicated in PID are thought to spread in three ways: Intra-abdominally, traveling from the

cervix to the endometrium, through the salpinx, and into the peritoneal cavity (causing endometritis, salpingitis, tubo-ovarian abscess, or pelvic peritonitis) Through the lymphatic systems, such as infection of the parametrium from an intrauterine device (IUD) Through hematogenous routes, such as with tuberculosis, although this is rare.6 Diagnosis The diagnosis of PID is based primarily on clinical evaluation. Because of the potential for signicant consequences if treatment is delayed, physicians should treat on the basis of clinical judgment without waiting for conrmation from laboratory or imaging tests. Most importantly, physicians must consider PID in the differential diagnosis in women 15 to 44 years of age who present with lower abdominal or pelvic pain and cervical motion or pelvic tenderness, even if these symptoms are mild. However, there is no single symptom, physical nding, or laboratory test that is sensitive or specic enough to denitively diagnose PID7; clinical diagnosis alone is 87 percent sensitive and 50 percent specic.8 When compared with laparoscopy, clinical diagnosis of PID in symptomatic patients has a positive predictive value of 65 to 90 percent.5 This depends on the risk factors within the population being evaluated.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical recommendation No single clinical nding or laboratory test is sensitive or specic enough to denitively diagnose PID. Empiric antibiotic treatment should be initiated at the time of presentation in patients with symptoms suspicious for PID, even if the diagnosis has not been conrmed. Women with mild to moderate PID may receive outpatient oral medical treatment without increased risk of long-term sequelae. Unless there is proven sensitivity, uoroquinolones should not be used in women with PID because of widespread resistance in Neisseria gonorrhoeae; a parenteral cephalosporin is recommended instead. Screening for lower genital tract chlamydial infection in younger and high-risk populations is recommended to reduce the incidence of PID. Asymptomatic disease should be treated. The frequency and cost-effectiveness of screening for asymptomatic lower genital tract chlamydial infection are not clear.
PID = pelvic inammatory disease. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp. org/afpsort.xml.

Evidence rating C B B C

References 7 15 18, 19 20

A C

26, 27 28, 29

HISTORY AND PHYSICAL EXAMINATION

The history should focus on high-risk behaviors and symptoms. Risk factors for PID include age younger than 25 years; young age at rst sexual encounter (younger than 15 years); use of nonbarrier contraception,

Table 1. Clinical Diagnostic Criteria for PID

One or more of the following minimum criteria must be present on pelvic examination to diagnose PID: Cervical motion tenderness Uterine tenderness Adnexal tenderness The following criteria can improve the specicity of the diagnosis: Oral temperature > 101F (> 38.3C) Abnormal cervical or vaginal mucopurulent discharge Presence of abundant numbers of white blood cells on saline microscopy of vaginal uid Elevated erythrocyte sedimentation rate Elevated C-reactive protein level Laboratory documentation of cervical infection with gonorrhea or chlamydia The following test results are the most specic criteria for diagnosing PID: Endometrial biopsy with histopathologic evidence of endometritis Transvaginal sonography or magnetic resonance imaging techniques showing thickened, uid-lled tubes with or without free pelvic uid or tubo-ovarian complex, or Doppler studies suggesting pelvic infection (e.g., tubal hyperemia) Laparoscopic abnormalities consistent with PID
PID = pelvic inammatory disease. Information from reference 5.

especially IUD or oral contraceptives; new, multiple, or symptomatic sex partners; a history of PID or sexually transmitted infection; or recent IUD insertion.9 Black women may be at higher risk of PID, although there are inconsistencies among physicians in their criteria for diagnosing PID and biases in reporting.1,10 Vaginal douching also may be a risk factor.11 Typically, women will present with some degree of lower abdominal or pelvic pain, although it may be mild. Other symptoms may include a new or abnormal vaginal discharge, fever or chills, cramping, dyspareunia, dysuria, and abnormal or postcoital bleeding. Some women also may have low back pain, nausea, and vomiting.6 It is less common for women to have no symptoms or atypical symptoms, such as right upper quadrant pain from perihepatitis (i.e., Fitz-HughCurtis syndrome). At-risk women who present with pelvic or lower abdominal pain and have no other identied etiology for their pain should be presumed to have PID if they have cervical motion, uterine, or adnexal tenderness. Additional diagnostic criteria are outlined in Table 1.5 The differential diagnosis also may include gastrointestinal conditions (e.g., acute appendicitis, inammatory bowel disease); genitourinary conditions (e.g., urinary tract infection/pyelonephritis, nephrolithiasis); obstetric/gynecologic conditions (e.g., ovarian tumor/cyst/torsion, ectopic pregnancy); or functional pelvic pain.
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Pelvic Inammatory Disease

DIAGNOSTIC STUDIES

Nucleic acid amplication tests (e.g., strand displacement amplication, ligase chain reaction, or polymerase chain reaction testing) for Chlamydia trachomatis and Neisseria gonorrhoeae are sensitive (90 to 98 percent and 88.9 to 95.2 percent, respectively), specic (98 to 100 percent and 99.1 to 100 percent, respectively), and cost-effective for documenting the presence of these organisms.12 These tests can be used for vaginal or endocervical specimens collected by the physician, vaginal specimens self-collected by the patient, or urine samples.13 Sensitivity to antimicrobial agents can be tested only on cultures. Saline microscopy can help determine if the patient has concurrent Trichomonas vaginalis infection or bacterial vaginosis.14 If the patients vaginal discharge is unchanged and there are no white blood cells present, then a diagnosis of PID is less likely, although it cannot be ruled out.11 Other diagnostic studies are rarely indicated unless there is no response to treatment. In addition to increasing the cost to the patient, these tests create additional risks from the procedure itself or from anesthesia. Although they are not needed routinely, the tests that are most specic for diagnosing PID include endometrial biopsy with histopathologic evidence of endometritis (74percent sensitive; 84 percent specic); transvaginal sonography (30 percent sensitive; 76 percent specic), particularly with Doppler ow assessment; magnetic resonance imaging techniques showing thickened, uid-lled tubes; or laparoscopic abnormalities consistent with salpingitis or peritonitis (81 percent sensitive; 100 percent specic).8 Patients who do not have a clear diagnosis despite radiologic studies or who are not responding to therapy may benet from laparoscopy. If no evidence of PID is identied after laparoscopy, endometrial biopsy may be required to evaluate for endometritis. Computed tomography has been used to diagnose PID; however, this is an insensitive and expensive test that is inaccessible to many high-risk patients, and generates extra radiation exposure.
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Treatment and Management According to consensus data, the treatment of PID must be empiric because a denitive diagnosis is rarely known or conrmed at the time of presentation.15 Empiric treatment may result in adverse Women with pelvic effects from the antibiotics, inammatory disease have including allergic reactions, gasa 20 percent chance of trointestinal symptoms, or drug developing infertility from resistance; however, the benets tubal scarring. are thought to outweigh the 5 risks. Because these infections are polymicrobial, broad-spectrum antimicrobial agents are recommended to cover the most likely pathogens. The antibiotics employed should be effective against C. trachomatis and N. gonorrhoeae even if the tests are negative, because women may have upper genital tract disease without cervical cultures that are positive for these organisms.5 There is controversy over the need for treatment that is effective against anaerobic bacteria in women with PID. Anaerobic microorganisms found in patients with PID may include anaerobic vaginal and cervical ora, such as bacterial vaginosisrelated organisms (e.g., Gardnerella vaginalis).16 Guidelines recommend targeting these organisms in the absence of denitive study outcomes. Mycoplasma genitalium infection has been associated with treatment failure in some women, and current treatment guidelines do not target this organism. More studies are needed to determine if treatments targeting this organism should be routinely recommended.17 Data comparing the effectiveness of different treatment regimens are limited; guidelines are updated to reect resistance patterns and additional organisms that are implicated in these infections. Initially, physicians should determine whether the patient requires inpatient or outpatient management.18 Criteria for hospitalization are listed in Table 2.5 Randomized clinical trials have demonstrated effectiveness of parenteral and oral antimicrobial agents in patients with mild or moderate PID.18 The oral and parenteral treatment regimen options are listed in Tables 3 and 4.5 The rst option for oral treatment includes a onetime 250-mg intramuscular dose of ceftriaxone (Rocephin) plus 100 mg of doxycycline
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Table 2. Suggested Criteria for Hospitalization of Patients with Pelvic Inammatory Disease
Inability to follow or tolerate an outpatient oral medication regimen No clinical response to oral antimicrobial therapy Pregnancy Severe illness, nausea and vomiting, or high fever Surgical emergencies (e.g., appendicitis) cannot be excluded Tubo-ovarian abscess
Information from reference 5.

orally twice per day for 14 days. Women with mild to moderate PID may receive outpatient oral medical treatment without increased risk of long-term sequelae.18,19 The patients age does not affect the response to treatment, whether inpatient or outpatient.
Table 3. Oral Treatment Regimens for Pelvic Inammatory Disease
Drug Option 1 Ceftriaxone (Rocephin) plus Doxycycline with or without Metronidazole (Flagyl) Option 2 Cefoxitin plus Doxycycline with or without Metronidazole Option 3 Other parenteral thirdgeneration cephalosporin (e.g., ceftizoxime [Cezox], cefotaxime [Claforan]) plus Doxycycline with or without Metronidazole
IM = intramuscularly. Adapted from Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010 [published correction appears in MMWR Morb Mortal Wkly Rep. 2011;60(1):18]. MMWR Recomm Rep. 2010;59(RR-12):66.

Dosage

250 mg IM in a single dose 100 mg orally twice per day for 14 days 500 mg orally twice per day for 14 days 2 g IM in a single dose administered concurrently with probenecid (1 g orally) 100 mg orally twice per day for 14 days 500 mg orally twice per day for 14 days

If parenteral therapy is required, the patient should be transitioned to oral treatment 24 to 48 hours after clinical improvement. Women with tubo-ovarian abscesses should have at least 24 hours of inpatient treatment, and may require additional treatment, such as surgery.18 There is widespread emergence of N. gonorrhoeae resistance to uoroquinolones, and these agents are no longer recommended unless there is a positive culture with conrmed sensitivity. Otherwise, a parenteral cephalosporin is suggested.20 Follow-up is important to ensure that the patient is responding to outpatient treatment. Clinical symptoms should improve within 72 hours of treatment, and if not, further evaluation is advised. Some patients may require additional testing to rule out other diagnoses, such as a tubo-ovarian abscess, and assessment is needed for additional antimicrobial therapy, parenteral antimicrobials, and hospitalization. Male partners of women with PID should be evaluated and treated if they have had sexual contact within 60 days of a diagnosis of PID.5 Men are often asymptomatic even when their partners are positive for chlamydia or gonorrhea. To decrease the chance of recurrence, women and their partners should abstain from sexual intercourse until they have completed the course of treatment. Women with PID should be counseled about the prevention of sexually transmitted infections and PID because there is a high risk of reinfection even when partners have been treated. Repeat testing for women with chlamydia or gonorrhea is suggested three to six months after treatment.21 Testing for human immunodeciency virus (HIV) infection and syphilis should be performed to rule out coexisting infections.
SPECIAL POPULATIONS

100 mg orally twice per day for 14 days 500 mg orally twice per day for 14 days

Women with HIV infection may be less likely to test positive for gonorrhea or chlamydia, but are more likely to have an infection from Mycoplasma or Streptococcus species.22 Oral and parenteral treatments are equally effective in women with and without HIV infection, unless there is a tubo-ovarian
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Table 4. Parenteral Treatment Regimens for Pelvic Inammatory Disease

Drug Dosage

abscess, which, though rare, occurs more often in those with HIV.23 PID is uncommon during pregnancy, although if it occurs, it is usually within the rst 12 weeks before the mucous plug can act as an adequate barrier. Pregnant women with suspected PID should be hospitalized and given parenteral antibiotics. PID during pregnancy increases the risk of preterm delivery and increases maternal morbidity.24 Women with IUDs have an increased risk of PID only within the rst three weeks after insertion of the IUD. There is no evidence that suggests removal of the IUD is necessary in patients with acute PID; however, close follow-up is recommended. Data indicate no difference in outcomes of PID in women with copper IUDs versus the levonorgestrelreleasing intrauterine system (Mirena). There are insufcient data to suggest that antibiotics should be given to patients at the time of IUD insertion to decrease the risk of developing infection.25 Screening and Prevention Screening for chlamydia and gonorrhea in young women has been shown to decrease the incidence of PID in high-risk populations. The U.S. Preventive Services Task Force recommends screening for chlamydia in all sexually active women younger than 25 years and in those 25 years and older at increased risk.26,27 There is evidence that screening more than once per year may be more effective than annual screening in high-risk groups. One study showed that 79 percent of the women who developed PID over a 12-month period tested negative on their annual chlamydia screening.28,29 Women should be screened each time they have a new sex partner. However, data are unclear on whether it is cost-effective to screen women who are asymptomatic for lower tract chlamydial infections.28,29 There is some evidence that adolescents respond to brief behavioral intervention at the time PID is diagnosed to increase the chances that their partners will receive treatment, thus decreasing recurrence.30 There is also evidence that counseling can help decrease the risk of PID in at-risk populations.31 Counseling about condom use can
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Regimen A Cefotetan (Cefotan) or Cefoxitin plus Doxycycline Regimen B Clindamycin plus Gentamicin

2 g IV every 12 hours 2 g IV every six hours 100 mg orally or IV every 12 hours 900 mg IV every eight hours Loading dose IV or IM (2 mg per kg), followed by a maintenance dose (1.5 mg per kg) every eight hours; a single daily dose (3 to 5 mg per kg) can be substituted 3 g IV every six hours

Alternative regimen Ampicillin/sulbactam (Unasyn) plus Doxycycline

100 mg orally or IV every 12 hours

IM = intramuscularly; IV = intravenously. Adapted from Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010 [published correction appears in MMWR Morb Mortal Wkly Rep. 2011;60(1):18]. MMWR Recomm Rep. 2010;59(RR-12):65.

decrease the risk of PID.32 Greater awareness about the importance of screening and adequate education on PID prevention are needed for high-risk populations.
The author thanks Justine Strand de Oliveira, DrPH, PA-C, for her review of the manuscript. Data Sources: A PubMed search was completed using the following key terms: PID, pelvic inammatory disease, sexually transmitted infections or sexually transmitted diseases AND chlamydia and gonorrhea. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Additional searches included the Agency for Healthcare Research and Quality evidence reports, U.S. Preventive Services Task Force, Clinical Evidence, the Cochrane database, Database of Abstracts of Reviews of Effects, the Institute for Clinical Systems Improvement, the National Guideline Clearinghouse, and UpToDate. Initial search date was March 30, 2011, and repeated June 15, 2011. A repeat search in PubMed, UpToDate, and the Cochrane database was performed October 10, 2011.

The Author
MARGARET GRADISON, MD, MHS-CL, FAAFP, is an associate professor in the Department of Community and Family Medicine at Duke University Medical Center in Durham, N.C. Address correspondence to Margaret Gradison, MD, MHS-CL, FAAFP, Duke University Medical Center,

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Pelvic Inammatory Disease

Department of Community and Family Medicine, Box 104780, Durham, NC 27710 (e-mail: gradi001@mc.duke. edu). Reprints are not available from the author. Author disclosure: No relevant nancial afliations to disclose. REFERENCES
1. Sutton MY, Sternberg M, Zaidi A, St Louis ME, Markowitz LE. Trends in pelvic inammatory disease hospital discharges and ambulatory visits, United States, 19852001. Sex Transm Dis. 2005;32(12):778-784. 2. Chesson HW, Collins D, Koski K. Formulas for estimating the costs averted by sexually transmitted infection (STI) prevention programs in the United States. Cost Eff Resour Alloc. 2008;6:10. 3. Haggerty CL, Gottlieb SL, Taylor BD, Low N, Xu F, Ness RB. Risk of sequelae after Chlamydia trachomatis genital infection in women. J Infect Dis. 2010;201(suppl 2): S134-S155. 4. Gottlieb SL, Berman SM, Low N. Screening and treatment to prevent sequelae in women with Chlamydia trachomatis genital infection: how much do we know? J Infect Dis. 2010;201(suppl 2):S156-S167. 5. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010 [published correction appears in MMWR Morb Mortal Wkly Rep. 2011;60(1):18]. MMWR Recomm Rep. 2010;59(RR-12):1-110. 6. Soper DE. Pelvic inammatory disease. Obstet Gynecol. 2010;116(2 pt 1):419-428. 7. Blenning CE, Muench J, Judkins DZ, Roberts KT. Clinical inquiries. Which tests are most useful for diagnosing PID? J Fam Pract. 2007;56(3):216-220. 8. Gaitn H, Angel E, Diaz R, Parada A, Sanchez L, Vargas C. Accuracy of ve different diagnostic techniques in mild-to-moderate pelvic inammatory disease. Infect Dis Obstet Gynecol. 2002;10(4):171-180. 9. Simms I, Stephenson JM, Mallinson H, et al. Risk factors associated with pelvic inammatory disease. Sex Transm Infect. 2006;82(6):452-457. 10. Doxanakis A, Hayes RD, Chen MY, et al. Missing pelvic inammatory disease? Substantial differences in the rate at which doctors diagnose PID. Sex Transm Infect. 2008;84(7):518-523. 11. Cottrell BH. An updated review of evidence to discourage douching. MCN Am J Matern Child Nurs. 2010;35(2):102-107. 12. Van Dyck E, Ieven M, Pattyn S, Van Damme L, Laga M. Detection of Chlamydia trachomatis and Neisseria gonorrhoeae by enzyme immunoassay, culture, and three nucleic acid amplication tests. J Clin Microbiol. 2001;39(5):1751-1756. 13. Cook RL, Hutchison SL, stergaard L, Braithwaite RS, Ness RB. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. 2005;142(11):914-925. 14. Hainer BL, Gibson MV. Vaginitis: diagnosis and treat ment. Am Fam Physician. 2011;83(7):807-815. 15. Ross JD. Pelvic inammatory disease. Clin Evid (Online). 2008;2008. 16. Ness RB, Kip KE, Hillier SL, et al. A cluster analysis of bac terial vaginosis-associated microora and pelvic inammatory disease. Am J Epidemiol. 2005;162(6):585-590.

17. Haggerty CL, Totten PA, Astete SG, et al. Failure of cefoxitin and doxycycline to eradicate endometrial Mycoplasma genitalium and the consequence for clinical cure of pelvic inammatory disease. Sex Transm Infect. 2008;84(5):338-342. 18. Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inammatory disease: results from the Pelvic Inammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol. 2002;186(5):929-937. 19. Ness RB, Trautmann G, Richter HE, et al. Effectiveness of treatment strategies of some women with pelvic inammatory disease: a randomized trial [published correction appears in Obstet Gynecol. 2006;107(6):1423-1425]. Obstet Gynecol. 2005;106(3):573-580. 20. Centers for Disease Control and Prevention (CDC). Update to CDCs sexually transmitted diseases treatment guidelines, 2006: uoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2007;56(14):332-336. 21. Hosenfeld CB, Workowski KA, Berman S, et al. Repeat infection with chlamydia and gonorrhea among females: a systematic review of the literature. Sex Transm Dis. 2009;36(8):478-489. 22. Irwin KL, Moorman AC, OSullivan MJ, et al. Inuence of human immunodeciency virus infection on pelvic inammatory disease. Obstet Gynecol. 2000;95(4):525-534. 23. Cohn SE, Clark RA. Sexually transmitted diseases, HIV, and AIDS in women. Med Clin North Am. 2003;87(5):971-995. 24. Zeger W, Holt K. Gynecologic infections. Emerg Med Clin North Am. 2003;21(3):631-648. 25. Grimes DA, Schulz KF. Antibiotic prophylaxis for intra uterine contraceptive device insertion. Cochrane Database Syst Rev. 2001;(2):CD001327. 26. U.S. Preventive Services Task Force. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2007;147(2):128-134. 27. Meyers DS, Halvorson H, Luckhaupt S; U.S. Preventive Services Task Force. Screening for chlamydial infection: an evidence update for the U.S. Preventive Services Task Force. Ann Intern Med. 2007;147(2):135-142. 28. Oakeshott P, Kerry S, Aghaizu A, et al. Randomised con trolled trial of screening for Chlamydia trachomatis to prevent pelvic inammatory disease: the POPI (prevention of pelvic infection) trial. BMJ. 2010;340:c1642. 29. Low N, Bender N, Nartey L, Shang A, Stephenson JM. Effectiveness of chlamydia screening: systematic review. Int J Epidemiol. 2009;38(2):435-448. 30. Trent M, Chung SE, Burke M, Walker A, Ellen JM. Results of a randomized controlled trial of a brief behavioral intervention for pelvic inammatory disease in adolescents. J Pediatr Adolesc Gynecol. 2010;23(2):96-101. 31. Lin JS, Whitlock E, OConnor E, Bauer V. Behavioral coun seling to prevent sexually transmitted infections: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149(7):497-508, W96-W99. 32. Ness RB, Randall H, Richter HE, et al.; Pelvic Inamma tory Disease Evaluation and Clinical Health Study Investigators. Condom use and the risk of recurrent pelvic inammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inammatory disease. Am J Public Health. 2004;94(8):1327-1329.

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