The diagnosis of acute pelvic inflammatory disease (PID) is usually based on clinical criteria and can be challenging for even the most astute clinicians. Although diagnostic accuracy is advocated, antibiotic treatment should be instituted if there is a diagnosis of cervicitis or suspicion of acute PID. Currently, no single test or combination of diagnostic indicators have been found to reliably predict PID, and laparoscopy cannot be recommended as a first line tool for PID diagnosis. For this reason, the clinician is left with maintaining a high index of suspicion for the diagnosis as he/she evaluates the lower genital tract for inflammation and the pelvic organs for tenderness in women with genital tract symptoms and a risk for sexually transmitted infection. This approach should minimize treating women without PID with antibiotics and optimize the diagnosis in a practical and cost-effective way.

Objective. To obtain pilot data on the endometrial histology of Depomedroxyprogesterone acetate (Depo-Provera, DMPA) users experiencing breakthrough bleeding (BTB) versus users with amenorrhea. To compare the endometrial histology of patients who used DMPA continuously for 3–12 months versus those who used it for 13 months or more. Methods. Cross-sectional study. Endometrial biopsy was obtained fromall consenting patients who used DMPA for at least 3 months. Patients were divided into those with BTB in the last 3 months versus those with amenorrhea for at least 3 months. Histology results and duration of therapy were compared. Results. The proportion of women with chronic endometritis, uterine polyps, atrophic, proliferative, or progesteronedominant endometrium did not differ between those DMPA users with BTB versus those with amenorrhea. Duration of therapy did not correlate with symptoms of BTB or endometrial histology. Chronic endometritis was the most common histologic finding (10/40, 25%) and occurred more often in women experiencing BTB (35% versus 15%) (RR 1.62 CI 0.91–2.87). Moreover, 45% of women with BTB had received DMPA for more than 12 months. Conclusions. BTB was more common than previously reported in women using DMPA for more than 12 months. Chronic endometritis, which may indicate an underlying infectious or intracavitary anatomic etiology, has not been previously reported as a frequent finding in DMPA users, and may be related to ethnic or other sociodemographic characteristics of our patient population. Further study to elucidate the etiology of chronic endometritis in these patients is warranted.

Awareness of the subspecialty of infectious diseases in obstetrics and gynecology is low among United States residents and residency directors. Objective. Given the burden of infectious diseases on women's health, we sought to assess current awareness, interest, and perceived value of the subspecialty of infectious diseases in obstetrics and gynecology among current United States obstetrics and gynecology residents and residency directors. Methods. Two separate surveys addressing awareness, perceived value and interest in the subspecialty were sent to (1) a random 20% sample of obstetrics and gynecology residents and (2) all obstetrics and gynecology residency directors. Results. Seventy percent of the residency directors were familiar with the subspecialty and 67.0% placed value on infectious disease specialists in an academic department. Thirty percent of the residents reported awareness of the subspecialty. Thirty-six percent of residency directors reported that medical infectious disease specialists deliver formal education to the obstetrics and gynecology residents. Conclusion. United States obstetrics and gynecology residents and residency directors have a low awareness of the subspecialty. An open niche exists for formal education of residents in infectious diseases in obstetrics and gynecology by department specialists. These findings can be incorporated into ongoing recruitment efforts for the subspecialty of infectious diseases in obstetrics and gynecology.

Dysuria is a common presenting complaint of women and urinalysis is a valuable tool in the initial evaluation of this presentation. Clinicians need to be aware that pyuria is the best determinate of bacteriuria requiring therapy and that values significant for infection differ depending on the method of analysis. A hemocytometer yields a value of ≥ 10 WBC/ mm3 significant for bacteriuria, while manual microscopy studies show ≥ 8 WBC/high-power field reliably predicts a positive urine culture. In cases of uncomplicated symptomatic urinary tract infection, a positive value for nitrites and leukocyte esterase by urine dipstick can be treated without the need for a urine culture. Automated urinalysis used widely in large volume laboratories provides more sensitive detection of leukocytes and bacteria in the urine.With automated microscopy, a value of > 2 WBC/hpf is significant pyuria indicative of inflammation of the urinary tract. In complicated cases such as pregnancy, recurrent infection or renal involvement, further evaluation is necessary including manual microscopy and urine culture with sensitivities.

Objective: We undertook the present study to attempt to apply clinical indicators predictive of cervical infection in nongravid populations with either Neisseria gonorrhoeae or Chlamydia trachomatis to our pregnant population and to determine the significance of the clinical diagnosis of “cervicitis.”

Methods: A retrospective chart review of all pregnant women with a final diagnosis of cervicitis who were seen in the Medical College of Virginia obstetrical emergency room was performed during the period of September 1991 to December 1992.

Results: Given the diagnosis of cervicitis in our emergency department, we found that the clinical examination predicted cervical infection with N. gonorrhoeae or C. trachomatis in only 20% of the pregnant women. Gravidas with chlamydial infections were younger (20.1 ± 3.7 years) compared with gravidas not infected (23.2 ± 5.4 years) (P < 0.0001). They were also more likely to have a diagnosis of lower urinary-tract infection [relative risk (RR) 2.89, 95% confidence interval (CI) 1.42–5.85].

Conclusions: The clinical indicators of cervical infection with C. trachomatis and N. gonorrhoeae were unreliable.

Effective therapies exist for the treatment of both vaginal trichomoniasis and bacterial vaginosis (BV). Recurrent trichomonas infection is uncommon, and significant metronidazole resistance remains rare. The management of metronidazole-resistant trichomoniasis is dependent on susceptibility studies, which can be used to guide higher doses of metronidazole therapy. Recurrent BV is common. A mechanism for reestablishing the normal vaginal flora with H2O2-producing lactobacilli remains elusive. The management of this recurrent infection is based upon a longer duration of therapy with currently available antibiotic regimens and documentation of a clinical response using composite clinical criteria and Gram's stain of the vaginal secretions.

Pelvic inflammatory disease (PID) is a serious public health and reproductive health problem in the United States. An early and accurate diagnosis of PID is extremely important for the effective management of the acute illness and for the prevention of long-term sequelae. The diagnosis of PID is difficult, with considerable numbers of false-positive and false-negative diagnoses. An abnormal vaginal discharge or evidence of lower genital tract infection is an important and predictive finding that is often underemphasized and overlooked. This paper reviews the clinical diagnosis and supportive laboratory tests for the diagnosis of PID and outlines an appropriate diagnostic plan for the clinician and the researcher.

Objective:To determine the effect of estrogen replacement therapy (ERT) on the vaginal flora of postmenopausal women.

Methods: Vaginal cultures were obtained from 15 postmenopausal women whose hormonal statuses were documented by serum follicle-stimulating hormone (FSH) and serum estrogen levels. After 8 weeks of ERT, consisting of 0.1 mg of estradiol delivered daily by dermal patch, the vaginal cultures were repeated, as were measurements of the vaginal pH, serum FSH, and serum estrogen levels.

Results: Vaginal cultures revealed no significant change in the incidence of lactobacilli or of all aerobes. However, the incidence of anaerobic species fell after treatment from 47% to 13% (P = 0.05), and the incidence of anaerobic gram-negative rods declined after treatment from 40% prior to ERT to 7% (P = 0.035). Prior to ERT, the difference in mean vaginal pH between lactobacilli-positive and lactobacilli-negative subjects was not significant, but, following the administration of exogenous estrogen, the lactobacilli-positive subjects exhibited a significantly lower mean vaginal pH (4.4 ± 0.4) relative to the lactobacilli-negative population (5.2 ± 0.3) (P = 0.02).

Conclusions: We conclude that women on ERT are less likely to have vaginal colonization with anaerobic bacteria when compared with women not using replacement therapy. Estrogen replacement may potentiate the effect of lactobacilli on vaginal pH.