Recurrent PID, Subsequent STI, and
Reproductive Health Outcomes:
Findings from the PID Evaluation and
Clinical Health (PEACH) Study
Maria Trent, MD, MPH
Debra Bass, MS
Roberta Ness, MD, MPH
Catherine Haggerty, PhD, MPH
Funding: Centers for Disease Control and Prevention: K01DP001128-02;
Agency for Healthcare Research and Quality Development: HS08358-05
Disclosures
• I have no relevant financial relationships with
the manufacturer(s) of any commercial
product(s) and/or providers (s) of commercial
services discussed in this CME activity.
• I do not intend to discuss off-label use of
products in this presentation
Background
• PID is a common reproductive health disorder
• Associated with significant reproductive morbidity:
– Tubal infertility
– Ectopic pregnancy
– Chronic pelvic pain (CPP)
• Risk estimates of morbidity based on Scandinavian
cohort of PID inpatients enrolled 1960 -1984
– Subsequent shifts in the biological organisms causing PID
– Management shifted to outpatient setting
• Re-analysis of the impact of recurrent PID and STIs
warranted
Objective
• To examine the risk of longitudinal adverse
outcomes associated with recurrent STIs and
PID among urban American women with mildmoderate PID
• To determine the potential impact of
adolescence on the observed longitudinal
outcomes
Methods
• Secondary data analysis
• PID Evaluation and Clinical Health
(PEACH)Study
– Women 14-38 years with mild-moderate PID
– Urban Settings in United States
– Randomized to inpatient/outpatient treatment
– Baseline interview & gynecologic exam
(endometrial biopsies, STI testing)
– Visits at 5 and 30 days
– Telephone interview quarterly x 84 months
Approach to Analysis
PEACH
831 Women 14-38 years Mild-Moderate PID
Randomized to Inpatient/ Outpatient Arms
Main PEACH Analysis
No Difference in Outcomes
by group
Re-Analysis based on
Recurrent PID/STI
Adolescent
Sub-Analysis
(≤19 yrs)
N=209
Methods
• Data evaluated using bivariate & multiple
regression analyses
• Analysis approved by Johns Hopkins IRB
Selected Demographics
Baseline Measure
Race/Ethnicity
Black
White
Hispanic
Native American/Alaskan Native
Insurance Status
Uninsured
Private
Public
Regular Access to Care
Ever Pregnant
Prior history of PID
New Sexual Partner
Any Contraceptive use past 4 weeks
% (N)
74.5% (621)
16.0% (133)
6.1% (51)
3.1% (26)
43.8% (364)
13.8% (115)
33.5% ( 278)
65% (539)
75.2% (625)
37.4% (311)
9.3% (78)
61.0% (508)
84-Month Reproductive Health
Outcomes
60%
57%
50%
43%
42%
40%
30%
Percentage
21%
20%
19%
10%
0%
PID
Infertility
CPP
Pregnancy
Live Birth
Subsequent STI & Reproductive Health
Outcomes: All Women
Subsequent
STI
(N = 195)
Pregnancy**
Live Birth*
Infertility
Chronic pelvic
pain
124 (63.6)
91 (46.7)
41 (21.0)
105 (53.8)
No
Subsequent
STI
(N = 596)
330 (55.4)
239 (40.1)
104 (17.4)
218 (37.7)
OR (95% CI)
Adjusted OR
(95% CI)*
1.4 (1.0 – 2.0)
1.3 (.09 – 1.8)
1.3 (0.8 – 1.9)
1.9 (1.4 – 2.7)
1.0 (0.7 – 1.5)
1.0 (0.7 – 1.4)
1.4 (0.9 – 2.2)
2.3 (1.6 – 3.2)
Outcomes by Recurrent PID Status:
ALL Women
Recurrent PID No Recurrent
(N = 168)
PID
(N = 621)
Pregnancy** 95 (56.5)
356 (57.3)
Live Birth* 61 (36.3)
270 (43.5)
Infertility
44 (26.2)
104 (16.7)
Chronic pelvic 115 (68.5)
213 (35.3)
pain
OR (95% CI)
Adjusted OR
(95% CI)*
1.0 (0.7 – 1.4)
0.7 (0.5 – 1.1)
1.8 (1.2 – 2.6)
4.0 (2.8 – 5.7)
1.0 (0.6 – 1.4)
0.7 (0.5 – 1.0)
1.8 (1.2 – 2.8)
4.2 (2.8 – 6.2)
Subsequent STI & Reproductive Health
Outcomes: Adolescent
Subsequent
STI
(N = 195)
Pregnancy**
Live Birth*
Infertility
Chronic pelvic
pain
124 (63.6)
91 (46.7)
41 (21.0)
105 (53.8)
No
Subsequent
STI
(N = 596)
330 (55.4)
239 (40.1)
104 (17.4)
218 (37.7)
OR (95% CI)
Adjusted OR
(95% CI)*
1.4 (1.0 – 2.0)
1.3 (.09 – 1.8)
1.3 (0.8 – 1.9)
1.9 (1.4 – 2.7)
1.0 (0.7 – 1.5)
1.0 (0.7 – 1.4)
1.4 (0.9 – 2.2)
2.3 (1.6 – 3.2)
Outcomes by Recurrent PID Status:
Adolescents
Recurrent PID No Recurrent OR (95% CI)
Adjusted OR
(N = 50)
PID
(95% CI)*
(N =149)
Pregnancy** 34 (68.0)
108 (72.5)
0.8 (0.4 – 1.6) 1.1 (0.5 – 2.2)
Live Birth
22 (44.0)
80 (53.7)
0.7 (0.4 – 1.3) 0.9 (0.4 – 1.7)
Infertility
13 (26.0)
23 (15.4)
1.9 (0.9 – 4.2) 1.9 (0.8 – 4.4)
Chronic pelvic
pain
34 (68.0)
44 (30.1)
4.9 (2.5 – 9.8)
5.0 (2.3 – 10.6)
Conclusions
• Women with recurrent PID are more likely to report
infertility and CPP at 84 months
• Substantiates the relationship between recurrent PID
and adverse
– Modern microbiology
– Outpatient and inpatient care approaches
• Highlights CPP as a major adverse outcome and
recurrent lower genital tract infection (STI) as a key
contributor
• Supports to the concept of tertiary prevention
– Upper genital tract disease = smaller, well defined public
health
– Adolescents are also an important sub-target
Limitations
• Limited Generalizability
– Demographics
– Trial Participation
• Contraception
• Clinical Criteria for PID
– Endometrial biopsies
– Mimics clinical practice
• Self-Reported Longitudinal Outcomes
– Supported by medical record review
Implications
• Young women with a history of PID are a
clearly defined target group for public health
intervention.
• Acute PID should prompt linkage of affected
patients to tailored STI risk-reduction services
to prevent the adverse outcomes associated
with PID