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IUD Toolkit

Up-to-date evidence and best practices related to the Intrauterine Device

Brought to you by USAID's Maximizing Access & Quality Initiative

When is a woman at very high individual risk of gonorrhea or chlamydia?

For IUD insertion, the World Health Organization (WHO) Medical Eligibility Criteria (MEC) state that for a woman with a “very high individual likelihood of exposure to gonorrhea or chlamydial infection, the condition is a Category 3.”¹

The statement was specifically written to ensure that an evaluation is made of the individual woman. The bar was deliberately placed at “very high” because even in the face of populations with prevalence levels of gonorrhea or chlamydia (GC/CT) as high as 10 percent, the risk of clinical pelvic inflammatory disease attributable to the IUD is still relatively low.

Still, this presents the challenge of defining the concept of “very high individual risk” and putting the definition into operation at the program level. A number of studies have been conducted to identify good determiners of risk, and some of these have been reasonably successful. However, indicators that are good predictors of infection at one site may not necessarily be as good at other sites. So there is no single algorithm to apply in all situations and no clear approach to this question.

Nevertheless, in keeping with the standard of “very high individual risk” some questions generally elicit answers that have a reasonable “positive predictive value.”² That is, if the answer to a question is yes, at least in some settings, there is some reasonable likelihood the client will indeed have GC/CT. This is the most reasonable approach available using client history even though, collectively, the questions may not be very “sensitive.” (That is they may not identify the majority of women who have GC/CT.)

Some such illustrative questions include:

Within the last three months, have you been told you have a sexually transmitted infection (STI)?
Within the last three months, have you had more than one sexual partner?
Do you think your partner has had another sexual partner within the last three months?
Within the last three months, has your partner been told he has an STI or has he had any penile discharge?
Do you believe you are at high risk of an STI?

End Notes:
¹Category 3 indicates the method is usually not recommended unless other more appropriate methods are not available or not acceptable. The risks of using the method usually outweigh the advantages, but if the client does use the method, careful follow-up will be required. For more information, see the WHO’s Medical Eligibility Criteria for Contraceptive Use.
²A positive predictive value reflects the proportion of patients who have a positive test result and truly have the disease in question. A test with a high positive predictive value indicates that the patient who has a positive test result probably has the disease.