Original research articleChronic endometritis in DMPA users and Chlamydia trachomatis endometritis
Introduction
Depo medroxyprogesterone acetate (DMPA or Depo-Provera) is a long-acting injectable contraceptive, approved for use in the United States in 1992 [1], [2], [3]. The most common side effect of DMPA is unscheduled or breakthrough bleeding (BTB), which occurs in 70% of patients in the first year and approximately 10% thereafter [1]. Unfortunately, 25% of patients discontinue this effective contraceptive in the first year because the bleeding is unacceptable [4]. Therapy for irregular bleeding on DMPA has had limited success [5], [6]. In a previous study, we reported a high rate of chronic endometritis (CE) among DMPA users with BTB [7]. The etiology of the CE was unknown, as all of the patients had no evidence of vaginal or cervical infection [7]. Chlamydia trachomatis (CT) cervicitis is a recognized cause of BTB among oral contraceptive pill (OCP) users [8]. Therefore, we wanted to determine the prevalence of CT endometritis in our DMPA users. It is important to understand the etiology of CE in DMPA users since nonhormonal treatments, such as antibiotics or nonsteroidal anti-inflammatory drugs (NSAIDs), may be more effective in treating BTB caused by a subclinical infection or CE. In this study, we performed polymerase chain reaction (PCR) studies for CT on the endometrial biopsy samples to determine the proportion of patients whose BTB symptoms are attributable to occult endometrial infection with CT.
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Materials and methods
This cross-sectional study was approved by the Institutional Review Board at the Medical University of South Carolina. The power analysis and methods used for this study are outlined in a previous publication [7]. All patients presenting to the outpatient gynecology clinic who used DMPA for at least 3 months were asked to participate in the study. We recruited the first 20 patients with BTB and the first 20 patients with amenorrhea on DMPA. Inclusion criteria were the ability to give informed
Results
Using this new PCR-based method, we found that CT was not a cause of CE among DMPA users with or without BTB. As shown in Table 1, only one patient in each cohort had CT infection, and neither of these patients had CE. None of the patients had a recent positive test for CT cervicitis or clinical evidence of CT cervicitis.
There was no difference in the rate of BV among patients with BTB (5/20) vs. those with amenorrhea (7/20) (p=.49). Also, there was no difference in the incidence of BV in
Discussion
In a previous study, we found a high prevalence of CE among DMPA users [7]. CE was more prevalent in DMPA users who were experiencing BTB [7]. CE has not been previously reported as a common histologic finding among DMPA users, and the purpose of this study was to determine whether CE was a marker of occult CT endometritis. It is known that BTB is a common presenting symptom of CE and CT infection [11], [12]. CE may be caused by infection or inflammation, thus determining the cause of CE will
Acknowledgment
There was no financial support for this study. We wish to thank Mr. Corey Eminger for technical and laboratory support.
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