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April 19, 1985, Vol 253, No. 15 >
ARTICLE | April 19, 1985

Oral Contraceptives, Chlamydia trachomatis Infection, and Pelvic Inflammatory Disease: Title and subTitle BreakA Word of Caution About Protection FREE

A. Eugene Washington, MD, MSc; Sandra Gove, MD, MPH; Julius Schachter, PhD; Richard L. Sweet, MD
[+] Author Affiliations

Reprint requests to Technical Information Services, Center for Prevention Services, Centers for Disease Control, Atlanta, GA 30333.


JAMA. 1985;253(15):2246-2250. doi:10.1001/jama.1985.03350390088032
Text Size: A A A
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Article
References

Management of pelvic inflammatory disease (PID) and decisions about contraception are being influenced by reports that oral contraceptives decrease the risk of PID. To evaluate the validity of this association, we have examined published epidemiologic evidence and reviewed relevant information from other disciplines. Current information does not permit the generalization that oral contraceptives protect against all forms of PID. Most studies conducted (1) have been limited to hospitalized women, who represent less than 25% of all PID cases and are likely to have relatively severe forms of the disease, and (2) have failed to distinguish between gonococcal and nongonococcal PID. While oral contraceptives may provide some protection against gonococcal PID, no basis exists for assuming similar protection is provided against chlamydial PID. In fact, epidemiologic and biologic evidence suggests that infection with Chlamydia trachomatis, the leading cause of nongonococcal PID, is enhanced by oral contraceptives. We judge the conclusion that oral contraceptives protect against all PID to be premature, and urge caution in its application in health policy and clinical decisions.

(JAMA 1985;253:2246-2250)

REFERENCES

1 +
Wright NH, Laemmle P:  Acute pelvic inflammatory disease in an indigent population . Am J Obstet Gynecol 1968;;101:979-990.
2 +
Targum SD, Wright NH:  Association of the intrauterine device and pelvic inflammatory disease: A retrospective pilot study . Am J Epidemiol 1974;;100:262-271.
3 +
Noonan AS, Adams JB:  Gonorrhoea screening in an urban hospital family planning program . Am J Public Health 1974;;64:700-704.
4 +
Faulkner WL, Ory HW:  Intrauterine devices and acute pelvic inflammatory disease . JAMA 1976;;235:1851-1853.
5 +
Eschenbach DA, Harnisch JP, Holmes KK:  Pathogenesis of acute pelvic inflammatory disease: Role of contraception and other risk factors . Am J Obstet Gynecol 1977;;128:838-850.
6 +
Ryden G, Fahraeus L, Molin L, et al:  Do contraceptives influence the incidence of acute pelvic inflammatory disease in women with gonorrhoea? Contraception 1979;;20:149-157.
7 +
Westrom L:  Incidence, prevalence, and trends of acute pelvic inflammatory disease and its consequences in industrialized countries . Am J Obstet Gynecol 1980;;138:880-892.
8 +
Osser S, Gullberg B, Liedholm P, et al:  Risk of pelvic inflammatory disease among intrauterine device users irrespective of previous pregnancy . Lancet 1980;;1:386-388.
9 +
Paavonen J, Vesterinen E:  Intrauterine contraceptive device use in patients with acute salpingitis . Contraception 1980;;22:107-114.
10 +
Rubin GL, Ory HW, Layde PM:  Oral contraceptives and pelvic inflammatory disease . Am J Obstet Gynecol 1982;;140:630-635.
11 +
Senanayake P, Kramer DG:  Contraception and the etiology of pelvic inflammatory disease: New perspectives . Am J Obstet Gynecol 1980;; 138:852-860.
12 +
Sherris JD, Fox G:  Infertility and sexually transmitted disease: A public health challenge . Popul Rep L 1983;;11:113-152.
13 +
Ory HW, Forrest JD, Lincoln R: Making Choices: Evaluating the Health Risks and Benefits of Birth Control Methods . New York, Alan Guttmacher Institute, 1983;.
14 +
Sweet RL, Gibbs R: Infectious Diseases in Obstetrics and Gynecology . Baltimore, Williams & Wilkins Co, in press.
15 +
Brunham RC:  Therapy for acute pelvic inflammatory disease: A critique of recent treatment trials . Am J Obstet Gynecol 1984;;148:235-240.
16 +
Svensson L, Westrom L, Ripa KT, et al:  Differences in some clinical and laboratory parameters in acute salpingitis related to culture and serologic findings . Am J Obstet Gynecol 1980;;138:1017-1021.
17 +
Svensson L, Mardh P-A, Westrom L:  Infertility after acute salpingitis with special reference to Chlamydia trachomatis . Fertil Steril 1983;;40:322-329.
18 +
Thompson SE, Washington AE:  Epidemiology of sexually transmitted Chlamydia trachomatis infections . Epidemiol Rev 1983;;5:96-123.
19 +
Sweet RL, Schachter J, Robbie MD:  Failure of β-lactam antibiotics to eradicate Chlamydia trachomatis in the endometrium despite apparent clinical cure of acute salpingitis . JAMA 1983;;250:2641-2645.
20 +
Sexually Transmitted Disease Statistical Letter 1982 . Atlanta, Centers for Disease Control, 1983;.
21 +
Washington AE, Cates W, Zaidi AA:  Hospitalizations for pelvic inflammatory disease: Epidemiology and trends in the United States, 1975-1981 . JAMA 1984;;251:2529-2533.
22 +
Holmes KK, Eschenbach DA, Knapp JS:  Salpingitis: Overview of etiology and epidemiology . Am J Obstet Gynecol 1980;;138:893-900.
23 +
Gump DW, Gibson M, Ashikaga T:  Evidence of prior pelvic inflammatory disease and its relationship to Chlamydia trachomatis antibody and intrauterine contraceptive device use in infertile women . Am J Obstet Gynecol 1983;; 146:153-159.
24 +
Hilton AL, Richmond SJ, Milne JD, et al:  Chlamydia A in the female genital tract . Br J Vener Dis 1974;;50:1-10.
25 +
Oriel JD, Powis PA, Reeve P, et al:  Chlamydial infections of the cervix . Br J Vener Dis 1974;;50:11-16.
26 +
Burns DCM, Darougar S, Thin RN, et al:  Isolation of Chlamydia from women attending a clinic for sexually transmitted diseases . Br J. Vener Dis 1975;;51:314-318.
27 +
Nayyar KC, O'Neill JJ, Hambling MH, et al:  Isolation of Chlamydia trachomatis from women attending a clinic for sexually transmitted diseases . Br J Vener Dis 1976;;52:396-398.
28 +
Woolfitt JMG, Watt L:  Chlamydial infection of the urogenital tract in promiscuous and non-promiscuous women . Br J Vener Dis 1977;; 53:93-95.
29 +
Oriel JD, Johnson AL, Barlow D, et al:  Infection of the uterine cervix with Chlamydia trachomatis . J Infect Dis 1978;;147:443-451.
30 +
Ripa KT, Svensson L, Mardh P-A, et al:  Chlamydia trachomatis cervicitis in gynecologic outpatients . Obstet Gynecol 1978;;52:698-702.
31 +
Tait IA, Rees E, Hobson D, et al:  Chlamydial infection of the cervix in contacts of men with nongonococcal urethritis . Br J Vener Dis 1980;;56:37-45.
32 +
Kinghorn GR, Waugh MA:  Oral contraceptive use and prevalence of infection with Chlamydia trachomatis in women . Br J Vener Dis 1981;;57:187-190.
33 +
Svensson L, Westrom L, Mardh P-A:  Chlamydia trachomatis in women attending a gynaecological outpatient clinic with lower genital tract infection . Br J Vener Dis 1981;;57:259-262.
34 +
Arya OP, Mallison H, Goddard AD:  Epidemiological and clinical correlates of chlamydial infection of the cervix . Br J Vener Dis 1981;; 57:118-124.
35 +
Schachter J, Stoner E, Moncada J:  Screening for chlamydial infections in women attending family planning clinics: Evaluation of presumptive indicators for therapy . West J Med 1983;;138:375-379.
36 +
Fraser JJ, Rettig PJ, Kaplan DW:  Prevalence of cervical Chlamydia trachomatis and Neisseria gonorrhoeae in female adolescents . Pediatrics 1983;;71:333-336.
37 +
Shafer M-A, Beck A, Blain B, et al:  Chlamydia trachomatis: Important relationships to race, contraception, lower genital tract infection, and Papanicolaou smear . J Pediatr 1984;; 104:141-146.
38 +
Jordan JA, Singer A:  Effect of oral contraceptive steroids upon epithelium and mucus , in Jordan JA, Singer A (eds): The Cervix . Philadelphia, WB Saunders Co, 1976;, pp 192-207.
39 +
Goldacre MJ, Loudon N, Watt B, et al:  Epidemiology and clinical significance of cervical erosion in women attending a family planning clinic . Br Med J 1978;;1:748-750.
40 +
Quinn RW, O'Reilly KR:  Contraceptive practices of women attending sexually transmitted disease clinic in Nashville, Tennessee . Sex Transm Dis , in press.
41 +
McCormack WM, Reynolds GH, Cooperative Study Group:  Effect of menstrual cycle and method of contraception on recovery of Neisseria gonorrhoeae . JAMA 1982;;247:1292-1294.
42 +
Noble RC, Kirk NM, Slagel WA, et al:  Recidivism among patients with gonococcal infection presenting to a venereal disease clinic . Sex Transm Dis 1977;;4:39-43.
43 +
Bhattacharyya N, Jephcott MB, Path C:  Diagnosis of gonorrhea in women: Influence of the contraceptive pill . J Am Vener Dis Assoc 1976;;2:21-24.
44 +
Hobson D, Karayiannia P, Byng RE, et al:  Quantitative aspects of chlamydial infection of the cervix . Br J Vener Dis 1980;;56:156-162.
45 +
Koch ML:  The bactericidal action of beta progesterone . Am J Obstet Gynecol 1950;;59:168-171.
46 +
Morse SA, Fitzgerald TJ:  Effect of progesterone on Neisseria gonorrhoeae . Infect Immun 1974;;10:1370-1377.
47 +
Salit IE:  The differential susceptibility of gonococcal opacity variants to sex hormones . Can J Microbiol 1982;;28:301-306.
48 +
Fitzgerald TJ, Morse SA:  Alteration of growth, infectivity, and viability of Neisseria gonorrhoeae by gonadal steroids . Can J Microbiol 1976;;22:286-294.
49 +
Tuffrey M, Taylor-Robinson D:  Progesterone as a key factor in the development of a mouse model for genital-tract infection with Chlamydia trachomatis . FEMS Microbiol Lett 1981;;12:111-115.
50 +
Taylor-Robinson D, Tuffrey M, Falder P:  Some aspects of animal models for Chlamydia trachomatis genital infection , in Mardh P-A, Holmes KK, Oriel JD, et al (eds): Chlamydial Infections . Amsterdam, Elsevier Biomedical Press, 1982;, pp 375-378.
51 +
Tuffrey M, Falder P, Taylor-Robinson D:  Genital-tract infection and disease in nude and immunologically competent mice after inoculation of a human strain of Chlamydia trachomatis . Br J Exp Pathol 1982;;63:539-546.
52 +
Rank RG, Barron AL:  Prolonged genital infection by GPIC agent associated with immunosuppression following treatment with estradiol , in Mardh P-A, Holmes KK, Oriel JD, et al (eds): Chlamydial Infections . Amsterdam, Elsevier Biomedical Press, 1982;, pp 391-394.
53 +
Rank RG, White HJ, Hough AJ, et al:  Effect of estradiol on chlamydial genital infection of female guinea pigs . Infect Immun 1982;; 38:699-705.
54 +
Pasley JN, Rank RG, Hough AJ, et al:  Effects of varying doses of estradiol on chlamydial genital infection in ovariectomized guinea pigs , abstracted, in Program and Abstracts of the Fifth Meeting of the International Society for STD Research, Seattle, Washington, August 1-3, 1983 . Seattle, International Society for STD Research, 1983;.
55 +
Barron AL, White HJ, Rank RG, et al:  A new animal model for the study of Chlamydia trachomatis genital infections: Infection of mice with the agent of mouse pneumonitis . J Infect Dis 1981;;143:63-66.
56 +
Moghissi KS, Syner FN, McBride L:  Contraceptive mechanism of microdose norethindrone . Obstet Gynecol 1973;;41:585-594.
57 +
Gillmer MD, Fox EJ, Jacobs HS:  Failure of withdrawal bleeding during combined oral contraceptive therapy: 'Amenorrhoea on the pill.' Contraception 1978;;18:507-515.
58 +
Sturtevant RP:  Long-term experience with Enovid among clinic patients: Results after 2 1/2 to six years of individual patient use . J Reprod Med 1970;;5:90-95.
59 +
Svensson L, Westrom L, Mardh P-A:  Contraceptives and acute salpingitis . JAMA 1984;; 251:2553-2555.
60 +
Berger GS, Keith L, Moss W:  Prevalence of gonorrhoea among women using various methods of contraception . Br J Vener Dis 1975;; 51:307-309.
61 +
McCormack WM, Rosner B, McComb DE, et al:  Infection with Chlamydia trachomatis in women college students . Am J Epidemiol 1985;; 121:107-115.
62 +
Summary and Recommendations of the NIAID Study Group on Sexually Transmitted Diseases . Bethesda, Md, National Institutes of Health, 1980;.
63 +
Stamm WE, Koutsky LA, Benedetti JK, et al:  Chlamydia trachomatis urethral infections in men: Prevalence, risk factors, and clinical manifestations . Ann Intern Med 1984;;100:47-51.
64 +
Brunham RC, Paavonen J, Stevens CE, et al:  Mucopurulent cervicitis: The ignored counterpart in women of urethritis in the male . N Engl J Med 1984;;311:1-6.
65 +
 Sexually transmitted diseases treatment guidelines 1982 . MMWR 1982;;31:33S-60S.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Wright NH, Laemmle P:  Acute pelvic inflammatory disease in an indigent population . Am J Obstet Gynecol 1968;;101:979-990.
2 +
Targum SD, Wright NH:  Association of the intrauterine device and pelvic inflammatory disease: A retrospective pilot study . Am J Epidemiol 1974;;100:262-271.
3 +
Noonan AS, Adams JB:  Gonorrhoea screening in an urban hospital family planning program . Am J Public Health 1974;;64:700-704.
4 +
Faulkner WL, Ory HW:  Intrauterine devices and acute pelvic inflammatory disease . JAMA 1976;;235:1851-1853.
5 +
Eschenbach DA, Harnisch JP, Holmes KK:  Pathogenesis of acute pelvic inflammatory disease: Role of contraception and other risk factors . Am J Obstet Gynecol 1977;;128:838-850.
6 +
Ryden G, Fahraeus L, Molin L, et al:  Do contraceptives influence the incidence of acute pelvic inflammatory disease in women with gonorrhoea? Contraception 1979;;20:149-157.
7 +
Westrom L:  Incidence, prevalence, and trends of acute pelvic inflammatory disease and its consequences in industrialized countries . Am J Obstet Gynecol 1980;;138:880-892.
8 +
Osser S, Gullberg B, Liedholm P, et al:  Risk of pelvic inflammatory disease among intrauterine device users irrespective of previous pregnancy . Lancet 1980;;1:386-388.
9 +
Paavonen J, Vesterinen E:  Intrauterine contraceptive device use in patients with acute salpingitis . Contraception 1980;;22:107-114.
10 +
Rubin GL, Ory HW, Layde PM:  Oral contraceptives and pelvic inflammatory disease . Am J Obstet Gynecol 1982;;140:630-635.
11 +
Senanayake P, Kramer DG:  Contraception and the etiology of pelvic inflammatory disease: New perspectives . Am J Obstet Gynecol 1980;; 138:852-860.
12 +
Sherris JD, Fox G:  Infertility and sexually transmitted disease: A public health challenge . Popul Rep L 1983;;11:113-152.
13 +
Ory HW, Forrest JD, Lincoln R: Making Choices: Evaluating the Health Risks and Benefits of Birth Control Methods . New York, Alan Guttmacher Institute, 1983;.
14 +
Sweet RL, Gibbs R: Infectious Diseases in Obstetrics and Gynecology . Baltimore, Williams & Wilkins Co, in press.
15 +
Brunham RC:  Therapy for acute pelvic inflammatory disease: A critique of recent treatment trials . Am J Obstet Gynecol 1984;;148:235-240.
16 +
Svensson L, Westrom L, Ripa KT, et al:  Differences in some clinical and laboratory parameters in acute salpingitis related to culture and serologic findings . Am J Obstet Gynecol 1980;;138:1017-1021.
17 +
Svensson L, Mardh P-A, Westrom L:  Infertility after acute salpingitis with special reference to Chlamydia trachomatis . Fertil Steril 1983;;40:322-329.
18 +
Thompson SE, Washington AE:  Epidemiology of sexually transmitted Chlamydia trachomatis infections . Epidemiol Rev 1983;;5:96-123.
19 +
Sweet RL, Schachter J, Robbie MD:  Failure of β-lactam antibiotics to eradicate Chlamydia trachomatis in the endometrium despite apparent clinical cure of acute salpingitis . JAMA 1983;;250:2641-2645.
20 +
Sexually Transmitted Disease Statistical Letter 1982 . Atlanta, Centers for Disease Control, 1983;.
21 +
Washington AE, Cates W, Zaidi AA:  Hospitalizations for pelvic inflammatory disease: Epidemiology and trends in the United States, 1975-1981 . JAMA 1984;;251:2529-2533.
22 +
Holmes KK, Eschenbach DA, Knapp JS:  Salpingitis: Overview of etiology and epidemiology . Am J Obstet Gynecol 1980;;138:893-900.
23 +
Gump DW, Gibson M, Ashikaga T:  Evidence of prior pelvic inflammatory disease and its relationship to Chlamydia trachomatis antibody and intrauterine contraceptive device use in infertile women . Am J Obstet Gynecol 1983;; 146:153-159.
24 +
Hilton AL, Richmond SJ, Milne JD, et al:  Chlamydia A in the female genital tract . Br J Vener Dis 1974;;50:1-10.
25 +
Oriel JD, Powis PA, Reeve P, et al:  Chlamydial infections of the cervix . Br J Vener Dis 1974;;50:11-16.
26 +
Burns DCM, Darougar S, Thin RN, et al:  Isolation of Chlamydia from women attending a clinic for sexually transmitted diseases . Br J. Vener Dis 1975;;51:314-318.
27 +
Nayyar KC, O'Neill JJ, Hambling MH, et al:  Isolation of Chlamydia trachomatis from women attending a clinic for sexually transmitted diseases . Br J Vener Dis 1976;;52:396-398.
28 +
Woolfitt JMG, Watt L:  Chlamydial infection of the urogenital tract in promiscuous and non-promiscuous women . Br J Vener Dis 1977;; 53:93-95.
29 +
Oriel JD, Johnson AL, Barlow D, et al:  Infection of the uterine cervix with Chlamydia trachomatis . J Infect Dis 1978;;147:443-451.
30 +
Ripa KT, Svensson L, Mardh P-A, et al:  Chlamydia trachomatis cervicitis in gynecologic outpatients . Obstet Gynecol 1978;;52:698-702.
31 +
Tait IA, Rees E, Hobson D, et al:  Chlamydial infection of the cervix in contacts of men with nongonococcal urethritis . Br J Vener Dis 1980;;56:37-45.
32 +
Kinghorn GR, Waugh MA:  Oral contraceptive use and prevalence of infection with Chlamydia trachomatis in women . Br J Vener Dis 1981;;57:187-190.
33 +
Svensson L, Westrom L, Mardh P-A:  Chlamydia trachomatis in women attending a gynaecological outpatient clinic with lower genital tract infection . Br J Vener Dis 1981;;57:259-262.
34 +
Arya OP, Mallison H, Goddard AD:  Epidemiological and clinical correlates of chlamydial infection of the cervix . Br J Vener Dis 1981;; 57:118-124.
35 +
Schachter J, Stoner E, Moncada J:  Screening for chlamydial infections in women attending family planning clinics: Evaluation of presumptive indicators for therapy . West J Med 1983;;138:375-379.
36 +
Fraser JJ, Rettig PJ, Kaplan DW:  Prevalence of cervical Chlamydia trachomatis and Neisseria gonorrhoeae in female adolescents . Pediatrics 1983;;71:333-336.
37 +
Shafer M-A, Beck A, Blain B, et al:  Chlamydia trachomatis: Important relationships to race, contraception, lower genital tract infection, and Papanicolaou smear . J Pediatr 1984;; 104:141-146.
38 +
Jordan JA, Singer A:  Effect of oral contraceptive steroids upon epithelium and mucus , in Jordan JA, Singer A (eds): The Cervix . Philadelphia, WB Saunders Co, 1976;, pp 192-207.
39 +
Goldacre MJ, Loudon N, Watt B, et al:  Epidemiology and clinical significance of cervical erosion in women attending a family planning clinic . Br Med J 1978;;1:748-750.
40 +
Quinn RW, O'Reilly KR:  Contraceptive practices of women attending sexually transmitted disease clinic in Nashville, Tennessee . Sex Transm Dis , in press.
41 +
McCormack WM, Reynolds GH, Cooperative Study Group:  Effect of menstrual cycle and method of contraception on recovery of Neisseria gonorrhoeae . JAMA 1982;;247:1292-1294.
42 +
Noble RC, Kirk NM, Slagel WA, et al:  Recidivism among patients with gonococcal infection presenting to a venereal disease clinic . Sex Transm Dis 1977;;4:39-43.
43 +
Bhattacharyya N, Jephcott MB, Path C:  Diagnosis of gonorrhea in women: Influence of the contraceptive pill . J Am Vener Dis Assoc 1976;;2:21-24.
44 +
Hobson D, Karayiannia P, Byng RE, et al:  Quantitative aspects of chlamydial infection of the cervix . Br J Vener Dis 1980;;56:156-162.
45 +
Koch ML:  The bactericidal action of beta progesterone . Am J Obstet Gynecol 1950;;59:168-171.
46 +
Morse SA, Fitzgerald TJ:  Effect of progesterone on Neisseria gonorrhoeae . Infect Immun 1974;;10:1370-1377.
47 +
Salit IE:  The differential susceptibility of gonococcal opacity variants to sex hormones . Can J Microbiol 1982;;28:301-306.
48 +
Fitzgerald TJ, Morse SA:  Alteration of growth, infectivity, and viability of Neisseria gonorrhoeae by gonadal steroids . Can J Microbiol 1976;;22:286-294.
49 +
Tuffrey M, Taylor-Robinson D:  Progesterone as a key factor in the development of a mouse model for genital-tract infection with Chlamydia trachomatis . FEMS Microbiol Lett 1981;;12:111-115.
50 +
Taylor-Robinson D, Tuffrey M, Falder P:  Some aspects of animal models for Chlamydia trachomatis genital infection , in Mardh P-A, Holmes KK, Oriel JD, et al (eds): Chlamydial Infections . Amsterdam, Elsevier Biomedical Press, 1982;, pp 375-378.
51 +
Tuffrey M, Falder P, Taylor-Robinson D:  Genital-tract infection and disease in nude and immunologically competent mice after inoculation of a human strain of Chlamydia trachomatis . Br J Exp Pathol 1982;;63:539-546.
52 +
Rank RG, Barron AL:  Prolonged genital infection by GPIC agent associated with immunosuppression following treatment with estradiol , in Mardh P-A, Holmes KK, Oriel JD, et al (eds): Chlamydial Infections . Amsterdam, Elsevier Biomedical Press, 1982;, pp 391-394.
53 +
Rank RG, White HJ, Hough AJ, et al:  Effect of estradiol on chlamydial genital infection of female guinea pigs . Infect Immun 1982;; 38:699-705.
54 +
Pasley JN, Rank RG, Hough AJ, et al:  Effects of varying doses of estradiol on chlamydial genital infection in ovariectomized guinea pigs , abstracted, in Program and Abstracts of the Fifth Meeting of the International Society for STD Research, Seattle, Washington, August 1-3, 1983 . Seattle, International Society for STD Research, 1983;.
55 +
Barron AL, White HJ, Rank RG, et al:  A new animal model for the study of Chlamydia trachomatis genital infections: Infection of mice with the agent of mouse pneumonitis . J Infect Dis 1981;;143:63-66.
56 +
Moghissi KS, Syner FN, McBride L:  Contraceptive mechanism of microdose norethindrone . Obstet Gynecol 1973;;41:585-594.
57 +
Gillmer MD, Fox EJ, Jacobs HS:  Failure of withdrawal bleeding during combined oral contraceptive therapy: 'Amenorrhoea on the pill.' Contraception 1978;;18:507-515.
58 +
Sturtevant RP:  Long-term experience with Enovid among clinic patients: Results after 2 1/2 to six years of individual patient use . J Reprod Med 1970;;5:90-95.
59 +
Svensson L, Westrom L, Mardh P-A:  Contraceptives and acute salpingitis . JAMA 1984;; 251:2553-2555.
60 +
Berger GS, Keith L, Moss W:  Prevalence of gonorrhoea among women using various methods of contraception . Br J Vener Dis 1975;; 51:307-309.
61 +
McCormack WM, Rosner B, McComb DE, et al:  Infection with Chlamydia trachomatis in women college students . Am J Epidemiol 1985;; 121:107-115.
62 +
Summary and Recommendations of the NIAID Study Group on Sexually Transmitted Diseases . Bethesda, Md, National Institutes of Health, 1980;.
63 +
Stamm WE, Koutsky LA, Benedetti JK, et al:  Chlamydia trachomatis urethral infections in men: Prevalence, risk factors, and clinical manifestations . Ann Intern Med 1984;;100:47-51.
64 +
Brunham RC, Paavonen J, Stevens CE, et al:  Mucopurulent cervicitis: The ignored counterpart in women of urethritis in the male . N Engl J Med 1984;;311:1-6.
65 +
 Sexually transmitted diseases treatment guidelines 1982 . MMWR 1982;;31:33S-60S.

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