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What are the benefits and risks of IUDs in adolescents?
LITTLE AVAILABLE EVIDENCE specifically addresses the benefits and risks of intrauterine devices (IUDs) in adolescents. Most studies have evaluated IUD use in nulliparous adults.
Levonorgestrel IUDs cause less menstrual bleeding than oral contraceptive pills (OCPs) in adult nulliparous women without differences in complications or pregnancy rates (strength of recommendation [SOR]: B, one RCT).
Levonorgestrel IUDs appear to have similar expulsion and continuation rates in adolescents and adults (SOR: B, one prospective study). Adult nulliparous women who discontinue IUDs have subsequent birth rates similar to women who stop using OCPs or barrier methods. (SOR: B, limited quality evidence).
Evidence summary
One RCT that compared the levonorgestrel IUD (Mirena) with oral contraceptives in 200 nulliparous women 18 to 25 years of age found the IUD to have equivalent safety and efficacy to OCPs.1 Moreover, the IUD group experienced a significant decrease in bleeding, with a number needed to treat of 4 (P=.001).
Neither group reported any pregnancies or pelvic inflammatory disease at one year. The overall discontinuation rate at one year was 20% for IUDs and 27% for OCPs (P=not significant [NS]).1 Multiple studies show no unintended pregnancies with the IUD.1-3
Study of adolescents finds low complication rate
A prospective cohort study of 179 adolescents 10 to 19 years of age found that the overall incidence of complications with the levonorgestrel IUD was relatively low, with removal rates of 8/179 (4.5%) each for pain and abnormal vaginal bleeding. The cumulative incidence of expulsion was estimated at 8.3% (95% confidence interval [CI], 4.2%-14.3%). No cases of uterine perforation were identified, and the one-year continuation rate was 85% (95% CI, 77%-90%).2 Other studies haven’t evaluated adolescents as a separate group.
IUDs are also well tolerated in an older cohort
A cohort study of 113 nulliparous women 16 to 30 years of age found insertion of a copper or levonorgestrel IUD to be well tolerated; no perforations were observed. At one year, 65 women (58%) still had their original IUD, 15 (13%) had had it removed, 6 (5%) had experienced expulsion, and 27 (24%) were lost to follow-up.3
Abdominal and back pain can be a problem
An RCT of 200 nulliparous women 18 to 25 years of age found that levonorgestrel IUDs were associated with more abdominal and back pain at 12 months than OCPs (54.7% of women with IUDs had pain vs 40% of women with OCPs; number needed to harm=7; P=.007). Pain was the leading cause of discontinuation in the IUD group (6 women with IUDs stopped using them vs no OCP users; P=.012).1
No difference in IUD complications in nulliparous vs parous women
A retrospective cohort study compared 129 nulliparous women with 332 parous women 17 to 52 years of age who had either copper or levonorgestrel IUDs. The researchers found no differences between the 2 groups in rates of perforation, pelvic inflammatory disease, ectopic pregnancy, or expulsion.4
Fertility after IUD removal: An encouraging picture
No studies have evaluated fertility after IUD use exclusively in adolescents. A prospective cohort study of 558 nulliparous women ages 18 to 40 years who stopped using a barrier method, copper IUD, or OCP in order to conceive found the quickest return to fertility among women who used the barrier method. The main outcome, percent of women who delivered within 12 months of discontinuation, was highest in the barrier method cohort and lowest in the OCP cohort (54% vs 32%; P=.002). The difference in delivery rates between the IUD and OCP groups at 12 months wasn’t statistically significant (39% vs 32%). By 18 months after cessation of contraception, the delivery rates in all 3 groups were similar (76%, 67%, and 70% for barrier, OCP, and IUD use, respectively).5
A retrospective cohort study that compared 36 nulliparous women with 83 parous women 18 to 41 years of age who were trying to conceive after removal of the GyneFix (copper) IUD found no statistical difference in pregnancy rates for age or duration of IUD use. Among women younger than 30 years, nulliparous women conceived earlier than parous women; cumulative pregnancy rates after 12 months were 100% for nulliparous and 80% for parous women (P=.007). No ectopic pregnancies were observed.6
Recommendations
The United Kingdom’s National Institute for Health and Clinical Excellence states that IUD use isn’t contraindicated in nulliparous women of any age, and that women of all ages may use IUDs. The Institute also states that no specific restrictions limit the use of copper or levonorgestrel IUDs by adolescents.
All women at risk for sexually transmitted infections may need to be tested before insertion. No evidence exists for a delay in return to fertility after removal or expulsion of an IUD.7
1. Suhonen S, Haukkamaa M, Jakobsson T, et al. Clinical performance of a levonorgestrel releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study. Contraception. 2004;69:407-412.
2. Paterson H, Ashton J, Harrison-Woolrych M. A nationwide cohort study of the use of the levonorgestrel intrauterine device in New Zealand adolescents. Contraception. 2009;79:433-438.
3. Brockmeyer A, Kishen M, Webb A. Experience of IUD/IUS insertions and clinical performance in nulliparous women—a pilot study. Eur J Contracept Reprod Health Care. 2008;13:248-254.
4. Veldhuis HM, Vos AG, Lagro-Janssen ALM. Complications of the intrauterine device in nulliparous and parous women. Eur J Gen Pract. 2004;10:82-87.
5. Doll H, Vessey M, Painter R. Return of fertility in nulliparous women after discontinuation of the intrauterine device: comparison with women discontinuing other methods of contraception. BJOG. 2001;108:304-314.
6. Delbarge W, Batar I, Bafort M, et al. Return to fertility in nulliparous women after removal of the GyneFix intrauterine contraceptive system. Eur J Contracept Reprod Health Care. 2002;7:24-30.
7. National Collaborating Centre for Women’s and Children’s Health, National Institute for Health and Clinical Excellence. Long-Acting Reversible Contraception: The Effect and Appropriate Use of Long-Acting Reversible Contraception. NICE Clinical Guidelines, No. 30. London, UK: RCOG Press; October 2005. Available at: http://www.ncbi.nlm.nih.gov/books/NBK51051. Accessed October 17, 2012.
LITTLE AVAILABLE EVIDENCE specifically addresses the benefits and risks of intrauterine devices (IUDs) in adolescents. Most studies have evaluated IUD use in nulliparous adults.
Levonorgestrel IUDs cause less menstrual bleeding than oral contraceptive pills (OCPs) in adult nulliparous women without differences in complications or pregnancy rates (strength of recommendation [SOR]: B, one RCT).
Levonorgestrel IUDs appear to have similar expulsion and continuation rates in adolescents and adults (SOR: B, one prospective study). Adult nulliparous women who discontinue IUDs have subsequent birth rates similar to women who stop using OCPs or barrier methods. (SOR: B, limited quality evidence).
Evidence summary
One RCT that compared the levonorgestrel IUD (Mirena) with oral contraceptives in 200 nulliparous women 18 to 25 years of age found the IUD to have equivalent safety and efficacy to OCPs.1 Moreover, the IUD group experienced a significant decrease in bleeding, with a number needed to treat of 4 (P=.001).
Neither group reported any pregnancies or pelvic inflammatory disease at one year. The overall discontinuation rate at one year was 20% for IUDs and 27% for OCPs (P=not significant [NS]).1 Multiple studies show no unintended pregnancies with the IUD.1-3
Study of adolescents finds low complication rate
A prospective cohort study of 179 adolescents 10 to 19 years of age found that the overall incidence of complications with the levonorgestrel IUD was relatively low, with removal rates of 8/179 (4.5%) each for pain and abnormal vaginal bleeding. The cumulative incidence of expulsion was estimated at 8.3% (95% confidence interval [CI], 4.2%-14.3%). No cases of uterine perforation were identified, and the one-year continuation rate was 85% (95% CI, 77%-90%).2 Other studies haven’t evaluated adolescents as a separate group.
IUDs are also well tolerated in an older cohort
A cohort study of 113 nulliparous women 16 to 30 years of age found insertion of a copper or levonorgestrel IUD to be well tolerated; no perforations were observed. At one year, 65 women (58%) still had their original IUD, 15 (13%) had had it removed, 6 (5%) had experienced expulsion, and 27 (24%) were lost to follow-up.3
Abdominal and back pain can be a problem
An RCT of 200 nulliparous women 18 to 25 years of age found that levonorgestrel IUDs were associated with more abdominal and back pain at 12 months than OCPs (54.7% of women with IUDs had pain vs 40% of women with OCPs; number needed to harm=7; P=.007). Pain was the leading cause of discontinuation in the IUD group (6 women with IUDs stopped using them vs no OCP users; P=.012).1
No difference in IUD complications in nulliparous vs parous women
A retrospective cohort study compared 129 nulliparous women with 332 parous women 17 to 52 years of age who had either copper or levonorgestrel IUDs. The researchers found no differences between the 2 groups in rates of perforation, pelvic inflammatory disease, ectopic pregnancy, or expulsion.4
Fertility after IUD removal: An encouraging picture
No studies have evaluated fertility after IUD use exclusively in adolescents. A prospective cohort study of 558 nulliparous women ages 18 to 40 years who stopped using a barrier method, copper IUD, or OCP in order to conceive found the quickest return to fertility among women who used the barrier method. The main outcome, percent of women who delivered within 12 months of discontinuation, was highest in the barrier method cohort and lowest in the OCP cohort (54% vs 32%; P=.002). The difference in delivery rates between the IUD and OCP groups at 12 months wasn’t statistically significant (39% vs 32%). By 18 months after cessation of contraception, the delivery rates in all 3 groups were similar (76%, 67%, and 70% for barrier, OCP, and IUD use, respectively).5
A retrospective cohort study that compared 36 nulliparous women with 83 parous women 18 to 41 years of age who were trying to conceive after removal of the GyneFix (copper) IUD found no statistical difference in pregnancy rates for age or duration of IUD use. Among women younger than 30 years, nulliparous women conceived earlier than parous women; cumulative pregnancy rates after 12 months were 100% for nulliparous and 80% for parous women (P=.007). No ectopic pregnancies were observed.6
Recommendations
The United Kingdom’s National Institute for Health and Clinical Excellence states that IUD use isn’t contraindicated in nulliparous women of any age, and that women of all ages may use IUDs. The Institute also states that no specific restrictions limit the use of copper or levonorgestrel IUDs by adolescents.
All women at risk for sexually transmitted infections may need to be tested before insertion. No evidence exists for a delay in return to fertility after removal or expulsion of an IUD.7
LITTLE AVAILABLE EVIDENCE specifically addresses the benefits and risks of intrauterine devices (IUDs) in adolescents. Most studies have evaluated IUD use in nulliparous adults.
Levonorgestrel IUDs cause less menstrual bleeding than oral contraceptive pills (OCPs) in adult nulliparous women without differences in complications or pregnancy rates (strength of recommendation [SOR]: B, one RCT).
Levonorgestrel IUDs appear to have similar expulsion and continuation rates in adolescents and adults (SOR: B, one prospective study). Adult nulliparous women who discontinue IUDs have subsequent birth rates similar to women who stop using OCPs or barrier methods. (SOR: B, limited quality evidence).
Evidence summary
One RCT that compared the levonorgestrel IUD (Mirena) with oral contraceptives in 200 nulliparous women 18 to 25 years of age found the IUD to have equivalent safety and efficacy to OCPs.1 Moreover, the IUD group experienced a significant decrease in bleeding, with a number needed to treat of 4 (P=.001).
Neither group reported any pregnancies or pelvic inflammatory disease at one year. The overall discontinuation rate at one year was 20% for IUDs and 27% for OCPs (P=not significant [NS]).1 Multiple studies show no unintended pregnancies with the IUD.1-3
Study of adolescents finds low complication rate
A prospective cohort study of 179 adolescents 10 to 19 years of age found that the overall incidence of complications with the levonorgestrel IUD was relatively low, with removal rates of 8/179 (4.5%) each for pain and abnormal vaginal bleeding. The cumulative incidence of expulsion was estimated at 8.3% (95% confidence interval [CI], 4.2%-14.3%). No cases of uterine perforation were identified, and the one-year continuation rate was 85% (95% CI, 77%-90%).2 Other studies haven’t evaluated adolescents as a separate group.
IUDs are also well tolerated in an older cohort
A cohort study of 113 nulliparous women 16 to 30 years of age found insertion of a copper or levonorgestrel IUD to be well tolerated; no perforations were observed. At one year, 65 women (58%) still had their original IUD, 15 (13%) had had it removed, 6 (5%) had experienced expulsion, and 27 (24%) were lost to follow-up.3
Abdominal and back pain can be a problem
An RCT of 200 nulliparous women 18 to 25 years of age found that levonorgestrel IUDs were associated with more abdominal and back pain at 12 months than OCPs (54.7% of women with IUDs had pain vs 40% of women with OCPs; number needed to harm=7; P=.007). Pain was the leading cause of discontinuation in the IUD group (6 women with IUDs stopped using them vs no OCP users; P=.012).1
No difference in IUD complications in nulliparous vs parous women
A retrospective cohort study compared 129 nulliparous women with 332 parous women 17 to 52 years of age who had either copper or levonorgestrel IUDs. The researchers found no differences between the 2 groups in rates of perforation, pelvic inflammatory disease, ectopic pregnancy, or expulsion.4
Fertility after IUD removal: An encouraging picture
No studies have evaluated fertility after IUD use exclusively in adolescents. A prospective cohort study of 558 nulliparous women ages 18 to 40 years who stopped using a barrier method, copper IUD, or OCP in order to conceive found the quickest return to fertility among women who used the barrier method. The main outcome, percent of women who delivered within 12 months of discontinuation, was highest in the barrier method cohort and lowest in the OCP cohort (54% vs 32%; P=.002). The difference in delivery rates between the IUD and OCP groups at 12 months wasn’t statistically significant (39% vs 32%). By 18 months after cessation of contraception, the delivery rates in all 3 groups were similar (76%, 67%, and 70% for barrier, OCP, and IUD use, respectively).5
A retrospective cohort study that compared 36 nulliparous women with 83 parous women 18 to 41 years of age who were trying to conceive after removal of the GyneFix (copper) IUD found no statistical difference in pregnancy rates for age or duration of IUD use. Among women younger than 30 years, nulliparous women conceived earlier than parous women; cumulative pregnancy rates after 12 months were 100% for nulliparous and 80% for parous women (P=.007). No ectopic pregnancies were observed.6
Recommendations
The United Kingdom’s National Institute for Health and Clinical Excellence states that IUD use isn’t contraindicated in nulliparous women of any age, and that women of all ages may use IUDs. The Institute also states that no specific restrictions limit the use of copper or levonorgestrel IUDs by adolescents.
All women at risk for sexually transmitted infections may need to be tested before insertion. No evidence exists for a delay in return to fertility after removal or expulsion of an IUD.7
1. Suhonen S, Haukkamaa M, Jakobsson T, et al. Clinical performance of a levonorgestrel releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study. Contraception. 2004;69:407-412.
2. Paterson H, Ashton J, Harrison-Woolrych M. A nationwide cohort study of the use of the levonorgestrel intrauterine device in New Zealand adolescents. Contraception. 2009;79:433-438.
3. Brockmeyer A, Kishen M, Webb A. Experience of IUD/IUS insertions and clinical performance in nulliparous women—a pilot study. Eur J Contracept Reprod Health Care. 2008;13:248-254.
4. Veldhuis HM, Vos AG, Lagro-Janssen ALM. Complications of the intrauterine device in nulliparous and parous women. Eur J Gen Pract. 2004;10:82-87.
5. Doll H, Vessey M, Painter R. Return of fertility in nulliparous women after discontinuation of the intrauterine device: comparison with women discontinuing other methods of contraception. BJOG. 2001;108:304-314.
6. Delbarge W, Batar I, Bafort M, et al. Return to fertility in nulliparous women after removal of the GyneFix intrauterine contraceptive system. Eur J Contracept Reprod Health Care. 2002;7:24-30.
7. National Collaborating Centre for Women’s and Children’s Health, National Institute for Health and Clinical Excellence. Long-Acting Reversible Contraception: The Effect and Appropriate Use of Long-Acting Reversible Contraception. NICE Clinical Guidelines, No. 30. London, UK: RCOG Press; October 2005. Available at: http://www.ncbi.nlm.nih.gov/books/NBK51051. Accessed October 17, 2012.
1. Suhonen S, Haukkamaa M, Jakobsson T, et al. Clinical performance of a levonorgestrel releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study. Contraception. 2004;69:407-412.
2. Paterson H, Ashton J, Harrison-Woolrych M. A nationwide cohort study of the use of the levonorgestrel intrauterine device in New Zealand adolescents. Contraception. 2009;79:433-438.
3. Brockmeyer A, Kishen M, Webb A. Experience of IUD/IUS insertions and clinical performance in nulliparous women—a pilot study. Eur J Contracept Reprod Health Care. 2008;13:248-254.
4. Veldhuis HM, Vos AG, Lagro-Janssen ALM. Complications of the intrauterine device in nulliparous and parous women. Eur J Gen Pract. 2004;10:82-87.
5. Doll H, Vessey M, Painter R. Return of fertility in nulliparous women after discontinuation of the intrauterine device: comparison with women discontinuing other methods of contraception. BJOG. 2001;108:304-314.
6. Delbarge W, Batar I, Bafort M, et al. Return to fertility in nulliparous women after removal of the GyneFix intrauterine contraceptive system. Eur J Contracept Reprod Health Care. 2002;7:24-30.
7. National Collaborating Centre for Women’s and Children’s Health, National Institute for Health and Clinical Excellence. Long-Acting Reversible Contraception: The Effect and Appropriate Use of Long-Acting Reversible Contraception. NICE Clinical Guidelines, No. 30. London, UK: RCOG Press; October 2005. Available at: http://www.ncbi.nlm.nih.gov/books/NBK51051. Accessed October 17, 2012.
Evidence-based answers from the Family Physicians Inquiries Network
Should you test or treat partners of patients with gonorrhea, chlamydia, or trichomoniasis?
GENERALLY SPEAKING, TREATING PARTNERS EMPIRICALLY IS AS EFFECTIVE or more effective than traditional referral and testing. Empiric treatment of partners of female or heterosexual male patients diagnosed with gonorrhea or chlamydia using expedited partner therapy (having the index patient deliver therapy to the partner) decreases the risk of persistent or recurrent infection in the index patient (strength of recommendation [SOR]: A, meta-analysis). The effect is greater for gonorrhea than chlamydia.
By contrast, expedited partner therapy for trichomoniasis appears equivalent to a test-first approach (SOR: B, single randomized controlled trial [RCT]).
No studies have evaluated empiric treatment of chlamydia, gonorrhea, or trichomoniasis in men who have sex with men. State laws vary with regard to expedited partner therapy and should be considered. Moreover, this type of empiric therapy misses the opportunity to counsel partners and treat comorbid disease, if present.
Evidence summary
Treating partners of patients with sexually transmitted infection has been a core component of therapy since the 1940s. Traditionally, partners have been referred to a health care provider (by the index patient, the provider, or a public health officer) for evaluation before being treated. Current methods of partner referral reach only 40% to 60% of named sexual partners.1
Expedited partner therapy vs traditional patient referral
Success of treatment is most readily measured by a reduction in the persistence or recurrence of infection in the index patient. Four RCTs and 1 observational cohort study have compared traditional patient referral with expedited partner treatment.2-6 The primary outcome measure in all studies was reduction of persistent or recurrent infection in the index patient ( TABLE 1 ).
Chlamydia. Of the 4 studies that evaluated expedited partner treatment for chlamydia, 1 cohort study showed a statistically significant decrease in recurrent or persistent chlamydial infection in index patients.2 One RCT showed a statistically significant reduction in recurrent or persistent urethritis, but didn’t report persistent and recurrent gonorrheal and chlamydial infections separately.3 Two RCTs showed a decrease in recurrent or persistent chlamydial infection in the index patient, but the difference didn’t reach statistical significance.4,5
Gonorrhea. Two RCTs evaluated expedited partner treatment for gonorrhea compared with patient referral. One demonstrated a statistically significant decrease in persistent or recurrent gonococcal infection.5 The other showed a statistically significant decrease in recurrent or persistent urethritis, but without identifying recurrent gonorrheal and chlamydial infections separately.3
Trichomoniasis. One RCT compared expedited partner therapy with patient referral for patients with trichomoniasis. The study didn’t show a statistically significant difference in recurrent or persistent infection.
TABLE 1
Traditional patient referral vs expedited partner treatment: How the 2 compare
| Patient population | Design | Outcomes | Favored treatment: PDPT vs PR | P value | NNT |
|---|---|---|---|---|---|
| Heterosexual men with N gonorrhoeae or C trachomatis2 | RCT | Recurrent/persistent N gonorrhoeae or C trachomatis | PDPT | <.001 | 5 |
| Women with C trachomatis3 | RCT | Recurrent/persistent C trachomatis | PDPT | .11 | 33.3 |
| Women and heterosexual men with N gonorrhoeae or C trachomatis4 | RCT | Recurrent/persistent N gonorrhoeae | PDPT | .01 | 12.5 |
| Recurrent/persistent C trachomatis | PDPT | .17 | 50 | ||
| Women with T vaginalis5 | RCT | Recurrent/persistent T vaginalis | PR | .64 | 32.3 |
| Women with C trachomatis6 | Observational cohort | Recurrent/persistent C trachomatis | PDPT | <.05 | 7.1 |
| C trachomatis, Chlamydia trachomatis; N gonorrhoeae, Neisseria gonorrhoeae; NNT, number needed to treat; PDPT, patient delivered partner therapy; PR, patient referral; RCT, randomized controlled trial; T vaginalis, Trichomonas vaginalis. | |||||
The verdict: Expedited partner therapy works better
A meta-analysis of the above studies evaluated the effect of expedited partner therapy compared with patient referral on the rate of recurrent or persistent gonorrhea, chlamydia, and trichomoniasis and the number of partners treated per index patient.1 Empiric therapy was associated with a lower rate of recurrent or persistent infections (risk ratio [RR]=0.73; 95% confidence interval [CI], 0.57-0.93) and a higher number of partners treated per patient (RR=1.44; 95% CI, 1.12-1.86).
Take state law into account
Providers need to consider their state’s laws regarding empiric partner therapy. A state-by-state evaluation of the legal status of expedited partner therapy is available on the Centers for Disease Control and Prevention’s Web site, and is summarized in TABLE 2.7
TABLE 2
What’s the status of expedited partner therapy (EPT) in your state?7
| EPT is permissible in 20 states: Arizona, California, Colorado, Illinois, Iowa, Louisiana, Minnesota, Mississippi, Nevada, New Hampshire, New Mexico, New York, North Dakota, Oregon, Pennsylvania, Tennessee, Texas, Utah, Washington, and Wyoming. (EPT is also permissible in Baltimore, MD.) |
| EPT is potentially allowable in 21 states: Alabama, Alaska, Connecticut, Delaware, Georgia, Hawaii, Idaho, Indiana, Kansas, Maine, Maryland, Massachusetts, Missouri, Montana, Nebraska, New Jersey, North Carolina, Rhode Island, South Dakota, Virginia, and Wisconsin. (EPT is also potentially allowable in the District of Columbia and Puerto Rico.) |
| EPT is prohibited in 9 states: Arkansas, Florida, Kentucky, Michigan, Ohio, Oklahoma, South Carolina, Vermont, and West Virginia |
Recommendations
A review of expedited partner therapy by the Centers for Disease Control and Prevention concluded: “The evidence indicates that expedited partner therapy should be available to clinicians as an option for partner management…[but it] does not replace other strategies such as standard patient referral or provider-assisted referral, when available…. Expedited partner therapy should be accompanied by information [advising] recipients to seek personal health care in addition to expedited partner therapy. Expedited partner therapy has a limited role in partner management for trichomoniasis. No data support its use in the routine management of syphilis, and there is no experience with expedited partner therapy for gonorrhea or chlamydial infection among men who have sex with men.”8
Neither the American Academy of Family Physicians nor the American College of Obstetricians and Gynecologists has issued a policy statement on expedited partner therapy.
Acknowledgments
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Medical Department of the United States Navy or the US Naval Service at large.
1. Trelle S, Shang A, Nartey, L, et al. Improved effectiveness of partner notification for patients with sexually transmitted infections: systematic review. BMJ. 2007;334:354-360.
2. Kissinger P, Mohammed H, Richardson-Alston G, et al. Patient-delivered partner treatment for male urethritis: a randomized, controlled trial. Clin Infect Dis. 2005;41:623-629.
3. Schillinger JA, Kissinger P, Calvet H, et al. Patient-delivered partner therapy with azithromycin to prevent repeated Chlamydia trachomatis infection among women: a randomized, controlled trial. Sex Transm Dis. 2003;30:49-56.
4. Golden MR, Whittington WL, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med. 2005;352:676-685.
5. Kissinger P, Schmidt N, Mohammed H, et al. Patient-delivered partner treatment for Trichomonas vaginalis infection: a randomized controlled trial. Sex Transm Dis. 2006;33:445-450.
6. Kissinger P, Brown R, Reed K, et al. Effectiveness of patient delivered partner medication for preventing recurrent Chlamydia trachomatis. Sex Transm Infect. 1998;74:331-333.
7. Centers for Disease Control and Prevention. Legal status of expedited partner therapy. Available at: http://www.cdc.gov/std/ept/legal/default.htm. Accessed December 10, 2009.
8. Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. Atlanta: US Department of Health and Human Services; 2006.
GENERALLY SPEAKING, TREATING PARTNERS EMPIRICALLY IS AS EFFECTIVE or more effective than traditional referral and testing. Empiric treatment of partners of female or heterosexual male patients diagnosed with gonorrhea or chlamydia using expedited partner therapy (having the index patient deliver therapy to the partner) decreases the risk of persistent or recurrent infection in the index patient (strength of recommendation [SOR]: A, meta-analysis). The effect is greater for gonorrhea than chlamydia.
By contrast, expedited partner therapy for trichomoniasis appears equivalent to a test-first approach (SOR: B, single randomized controlled trial [RCT]).
No studies have evaluated empiric treatment of chlamydia, gonorrhea, or trichomoniasis in men who have sex with men. State laws vary with regard to expedited partner therapy and should be considered. Moreover, this type of empiric therapy misses the opportunity to counsel partners and treat comorbid disease, if present.
Evidence summary
Treating partners of patients with sexually transmitted infection has been a core component of therapy since the 1940s. Traditionally, partners have been referred to a health care provider (by the index patient, the provider, or a public health officer) for evaluation before being treated. Current methods of partner referral reach only 40% to 60% of named sexual partners.1
Expedited partner therapy vs traditional patient referral
Success of treatment is most readily measured by a reduction in the persistence or recurrence of infection in the index patient. Four RCTs and 1 observational cohort study have compared traditional patient referral with expedited partner treatment.2-6 The primary outcome measure in all studies was reduction of persistent or recurrent infection in the index patient ( TABLE 1 ).
Chlamydia. Of the 4 studies that evaluated expedited partner treatment for chlamydia, 1 cohort study showed a statistically significant decrease in recurrent or persistent chlamydial infection in index patients.2 One RCT showed a statistically significant reduction in recurrent or persistent urethritis, but didn’t report persistent and recurrent gonorrheal and chlamydial infections separately.3 Two RCTs showed a decrease in recurrent or persistent chlamydial infection in the index patient, but the difference didn’t reach statistical significance.4,5
Gonorrhea. Two RCTs evaluated expedited partner treatment for gonorrhea compared with patient referral. One demonstrated a statistically significant decrease in persistent or recurrent gonococcal infection.5 The other showed a statistically significant decrease in recurrent or persistent urethritis, but without identifying recurrent gonorrheal and chlamydial infections separately.3
Trichomoniasis. One RCT compared expedited partner therapy with patient referral for patients with trichomoniasis. The study didn’t show a statistically significant difference in recurrent or persistent infection.
TABLE 1
Traditional patient referral vs expedited partner treatment: How the 2 compare
| Patient population | Design | Outcomes | Favored treatment: PDPT vs PR | P value | NNT |
|---|---|---|---|---|---|
| Heterosexual men with N gonorrhoeae or C trachomatis2 | RCT | Recurrent/persistent N gonorrhoeae or C trachomatis | PDPT | <.001 | 5 |
| Women with C trachomatis3 | RCT | Recurrent/persistent C trachomatis | PDPT | .11 | 33.3 |
| Women and heterosexual men with N gonorrhoeae or C trachomatis4 | RCT | Recurrent/persistent N gonorrhoeae | PDPT | .01 | 12.5 |
| Recurrent/persistent C trachomatis | PDPT | .17 | 50 | ||
| Women with T vaginalis5 | RCT | Recurrent/persistent T vaginalis | PR | .64 | 32.3 |
| Women with C trachomatis6 | Observational cohort | Recurrent/persistent C trachomatis | PDPT | <.05 | 7.1 |
| C trachomatis, Chlamydia trachomatis; N gonorrhoeae, Neisseria gonorrhoeae; NNT, number needed to treat; PDPT, patient delivered partner therapy; PR, patient referral; RCT, randomized controlled trial; T vaginalis, Trichomonas vaginalis. | |||||
The verdict: Expedited partner therapy works better
A meta-analysis of the above studies evaluated the effect of expedited partner therapy compared with patient referral on the rate of recurrent or persistent gonorrhea, chlamydia, and trichomoniasis and the number of partners treated per index patient.1 Empiric therapy was associated with a lower rate of recurrent or persistent infections (risk ratio [RR]=0.73; 95% confidence interval [CI], 0.57-0.93) and a higher number of partners treated per patient (RR=1.44; 95% CI, 1.12-1.86).
Take state law into account
Providers need to consider their state’s laws regarding empiric partner therapy. A state-by-state evaluation of the legal status of expedited partner therapy is available on the Centers for Disease Control and Prevention’s Web site, and is summarized in TABLE 2.7
TABLE 2
What’s the status of expedited partner therapy (EPT) in your state?7
| EPT is permissible in 20 states: Arizona, California, Colorado, Illinois, Iowa, Louisiana, Minnesota, Mississippi, Nevada, New Hampshire, New Mexico, New York, North Dakota, Oregon, Pennsylvania, Tennessee, Texas, Utah, Washington, and Wyoming. (EPT is also permissible in Baltimore, MD.) |
| EPT is potentially allowable in 21 states: Alabama, Alaska, Connecticut, Delaware, Georgia, Hawaii, Idaho, Indiana, Kansas, Maine, Maryland, Massachusetts, Missouri, Montana, Nebraska, New Jersey, North Carolina, Rhode Island, South Dakota, Virginia, and Wisconsin. (EPT is also potentially allowable in the District of Columbia and Puerto Rico.) |
| EPT is prohibited in 9 states: Arkansas, Florida, Kentucky, Michigan, Ohio, Oklahoma, South Carolina, Vermont, and West Virginia |
Recommendations
A review of expedited partner therapy by the Centers for Disease Control and Prevention concluded: “The evidence indicates that expedited partner therapy should be available to clinicians as an option for partner management…[but it] does not replace other strategies such as standard patient referral or provider-assisted referral, when available…. Expedited partner therapy should be accompanied by information [advising] recipients to seek personal health care in addition to expedited partner therapy. Expedited partner therapy has a limited role in partner management for trichomoniasis. No data support its use in the routine management of syphilis, and there is no experience with expedited partner therapy for gonorrhea or chlamydial infection among men who have sex with men.”8
Neither the American Academy of Family Physicians nor the American College of Obstetricians and Gynecologists has issued a policy statement on expedited partner therapy.
Acknowledgments
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Medical Department of the United States Navy or the US Naval Service at large.
GENERALLY SPEAKING, TREATING PARTNERS EMPIRICALLY IS AS EFFECTIVE or more effective than traditional referral and testing. Empiric treatment of partners of female or heterosexual male patients diagnosed with gonorrhea or chlamydia using expedited partner therapy (having the index patient deliver therapy to the partner) decreases the risk of persistent or recurrent infection in the index patient (strength of recommendation [SOR]: A, meta-analysis). The effect is greater for gonorrhea than chlamydia.
By contrast, expedited partner therapy for trichomoniasis appears equivalent to a test-first approach (SOR: B, single randomized controlled trial [RCT]).
No studies have evaluated empiric treatment of chlamydia, gonorrhea, or trichomoniasis in men who have sex with men. State laws vary with regard to expedited partner therapy and should be considered. Moreover, this type of empiric therapy misses the opportunity to counsel partners and treat comorbid disease, if present.
Evidence summary
Treating partners of patients with sexually transmitted infection has been a core component of therapy since the 1940s. Traditionally, partners have been referred to a health care provider (by the index patient, the provider, or a public health officer) for evaluation before being treated. Current methods of partner referral reach only 40% to 60% of named sexual partners.1
Expedited partner therapy vs traditional patient referral
Success of treatment is most readily measured by a reduction in the persistence or recurrence of infection in the index patient. Four RCTs and 1 observational cohort study have compared traditional patient referral with expedited partner treatment.2-6 The primary outcome measure in all studies was reduction of persistent or recurrent infection in the index patient ( TABLE 1 ).
Chlamydia. Of the 4 studies that evaluated expedited partner treatment for chlamydia, 1 cohort study showed a statistically significant decrease in recurrent or persistent chlamydial infection in index patients.2 One RCT showed a statistically significant reduction in recurrent or persistent urethritis, but didn’t report persistent and recurrent gonorrheal and chlamydial infections separately.3 Two RCTs showed a decrease in recurrent or persistent chlamydial infection in the index patient, but the difference didn’t reach statistical significance.4,5
Gonorrhea. Two RCTs evaluated expedited partner treatment for gonorrhea compared with patient referral. One demonstrated a statistically significant decrease in persistent or recurrent gonococcal infection.5 The other showed a statistically significant decrease in recurrent or persistent urethritis, but without identifying recurrent gonorrheal and chlamydial infections separately.3
Trichomoniasis. One RCT compared expedited partner therapy with patient referral for patients with trichomoniasis. The study didn’t show a statistically significant difference in recurrent or persistent infection.
TABLE 1
Traditional patient referral vs expedited partner treatment: How the 2 compare
| Patient population | Design | Outcomes | Favored treatment: PDPT vs PR | P value | NNT |
|---|---|---|---|---|---|
| Heterosexual men with N gonorrhoeae or C trachomatis2 | RCT | Recurrent/persistent N gonorrhoeae or C trachomatis | PDPT | <.001 | 5 |
| Women with C trachomatis3 | RCT | Recurrent/persistent C trachomatis | PDPT | .11 | 33.3 |
| Women and heterosexual men with N gonorrhoeae or C trachomatis4 | RCT | Recurrent/persistent N gonorrhoeae | PDPT | .01 | 12.5 |
| Recurrent/persistent C trachomatis | PDPT | .17 | 50 | ||
| Women with T vaginalis5 | RCT | Recurrent/persistent T vaginalis | PR | .64 | 32.3 |
| Women with C trachomatis6 | Observational cohort | Recurrent/persistent C trachomatis | PDPT | <.05 | 7.1 |
| C trachomatis, Chlamydia trachomatis; N gonorrhoeae, Neisseria gonorrhoeae; NNT, number needed to treat; PDPT, patient delivered partner therapy; PR, patient referral; RCT, randomized controlled trial; T vaginalis, Trichomonas vaginalis. | |||||
The verdict: Expedited partner therapy works better
A meta-analysis of the above studies evaluated the effect of expedited partner therapy compared with patient referral on the rate of recurrent or persistent gonorrhea, chlamydia, and trichomoniasis and the number of partners treated per index patient.1 Empiric therapy was associated with a lower rate of recurrent or persistent infections (risk ratio [RR]=0.73; 95% confidence interval [CI], 0.57-0.93) and a higher number of partners treated per patient (RR=1.44; 95% CI, 1.12-1.86).
Take state law into account
Providers need to consider their state’s laws regarding empiric partner therapy. A state-by-state evaluation of the legal status of expedited partner therapy is available on the Centers for Disease Control and Prevention’s Web site, and is summarized in TABLE 2.7
TABLE 2
What’s the status of expedited partner therapy (EPT) in your state?7
| EPT is permissible in 20 states: Arizona, California, Colorado, Illinois, Iowa, Louisiana, Minnesota, Mississippi, Nevada, New Hampshire, New Mexico, New York, North Dakota, Oregon, Pennsylvania, Tennessee, Texas, Utah, Washington, and Wyoming. (EPT is also permissible in Baltimore, MD.) |
| EPT is potentially allowable in 21 states: Alabama, Alaska, Connecticut, Delaware, Georgia, Hawaii, Idaho, Indiana, Kansas, Maine, Maryland, Massachusetts, Missouri, Montana, Nebraska, New Jersey, North Carolina, Rhode Island, South Dakota, Virginia, and Wisconsin. (EPT is also potentially allowable in the District of Columbia and Puerto Rico.) |
| EPT is prohibited in 9 states: Arkansas, Florida, Kentucky, Michigan, Ohio, Oklahoma, South Carolina, Vermont, and West Virginia |
Recommendations
A review of expedited partner therapy by the Centers for Disease Control and Prevention concluded: “The evidence indicates that expedited partner therapy should be available to clinicians as an option for partner management…[but it] does not replace other strategies such as standard patient referral or provider-assisted referral, when available…. Expedited partner therapy should be accompanied by information [advising] recipients to seek personal health care in addition to expedited partner therapy. Expedited partner therapy has a limited role in partner management for trichomoniasis. No data support its use in the routine management of syphilis, and there is no experience with expedited partner therapy for gonorrhea or chlamydial infection among men who have sex with men.”8
Neither the American Academy of Family Physicians nor the American College of Obstetricians and Gynecologists has issued a policy statement on expedited partner therapy.
Acknowledgments
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Medical Department of the United States Navy or the US Naval Service at large.
1. Trelle S, Shang A, Nartey, L, et al. Improved effectiveness of partner notification for patients with sexually transmitted infections: systematic review. BMJ. 2007;334:354-360.
2. Kissinger P, Mohammed H, Richardson-Alston G, et al. Patient-delivered partner treatment for male urethritis: a randomized, controlled trial. Clin Infect Dis. 2005;41:623-629.
3. Schillinger JA, Kissinger P, Calvet H, et al. Patient-delivered partner therapy with azithromycin to prevent repeated Chlamydia trachomatis infection among women: a randomized, controlled trial. Sex Transm Dis. 2003;30:49-56.
4. Golden MR, Whittington WL, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med. 2005;352:676-685.
5. Kissinger P, Schmidt N, Mohammed H, et al. Patient-delivered partner treatment for Trichomonas vaginalis infection: a randomized controlled trial. Sex Transm Dis. 2006;33:445-450.
6. Kissinger P, Brown R, Reed K, et al. Effectiveness of patient delivered partner medication for preventing recurrent Chlamydia trachomatis. Sex Transm Infect. 1998;74:331-333.
7. Centers for Disease Control and Prevention. Legal status of expedited partner therapy. Available at: http://www.cdc.gov/std/ept/legal/default.htm. Accessed December 10, 2009.
8. Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. Atlanta: US Department of Health and Human Services; 2006.
1. Trelle S, Shang A, Nartey, L, et al. Improved effectiveness of partner notification for patients with sexually transmitted infections: systematic review. BMJ. 2007;334:354-360.
2. Kissinger P, Mohammed H, Richardson-Alston G, et al. Patient-delivered partner treatment for male urethritis: a randomized, controlled trial. Clin Infect Dis. 2005;41:623-629.
3. Schillinger JA, Kissinger P, Calvet H, et al. Patient-delivered partner therapy with azithromycin to prevent repeated Chlamydia trachomatis infection among women: a randomized, controlled trial. Sex Transm Dis. 2003;30:49-56.
4. Golden MR, Whittington WL, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med. 2005;352:676-685.
5. Kissinger P, Schmidt N, Mohammed H, et al. Patient-delivered partner treatment for Trichomonas vaginalis infection: a randomized controlled trial. Sex Transm Dis. 2006;33:445-450.
6. Kissinger P, Brown R, Reed K, et al. Effectiveness of patient delivered partner medication for preventing recurrent Chlamydia trachomatis. Sex Transm Infect. 1998;74:331-333.
7. Centers for Disease Control and Prevention. Legal status of expedited partner therapy. Available at: http://www.cdc.gov/std/ept/legal/default.htm. Accessed December 10, 2009.
8. Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. Atlanta: US Department of Health and Human Services; 2006.
Evidence-based answers from the Family Physicians Inquiries Network