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And we're all waiting for those four brilliant letters that makes us all feel nice. N, I, L, M, nilm, which is negative for intraepithelial lesion or malignancy. Even better. Of course, if the CO test shows negative for hpv, either high risk types or any other type of high risk human papillomavirus, that's great. So we get our cervical cytology result back and it's nil. Perfect. Check that box. Next. There's no presence of HPV, either high risk or other high risk type. Non 16 or 18. Check the box. And then. Oh, my gosh, you thought you're just about to exit this whole issue fine in the clear. You see words right underneath. Oh. Incidental finding of organisms that are compatible with actinomycosis. Well, what do we do for that? No, God, no. God, please, no, no. Yep. It's so close. We're about to get out of the result with a completely normal result. Everything's fine. You're about to message the patient that she's all good until. Oh, what, five years of her doing the CO test, But no, there it is. Oh. Organisms compatible with actinomycosis. Oh, God, no. God, please, no, no, no. All right, maybe it's not that dramatic, but it does put a wrench in things because now you're like, oh, now I gotta message the patient. She's gonna freak out. I gotta explain this thing. And we've learned a lot about actinomycosis. Traditionally, actinomycosis Israeli. And what to do with this thing when we find it as an incidental finding, because the vast majority of patients are asymptomatic when we find this on liquid based cytology. Now, let me just let you know where we're going here. This comes from a real question, a real scenario sent from one of our podcast family members where this thing happened. Hey, I did a routine cervical cytology screen and everything was good, except it found actinomycosis actinomyces in this result. And she's having some kind of vague pain. What do I do with that? I'm like, ah, that's a really good podcast topic. Of course I sent her some information which we're going to cover here. But we've learned a lot. Just like urea plasma. Now, mycoplasma in general should not belong in the vagina. However, ureaplasma sometimes is part of the normal flora. That's okay. And things get kind of gray with this because we were originally taught, at least I was, that actinomyces is always pathogenic. It shouldn't be there. This anaerobic, kind of strange, kind of an oddball bacteria is a problem. Well, we now know that that's not the case. Actually, according to the Infectious Disease Society of America guidelines, about 7% of otherwise just healthy women can actually have this as part of their natural vaginal and urogenital tract flora. About 7%. Now we also know that the incidence of this bacteria colonization is actually higher in IUD wearing women. And it actually varies by type of IUD. So copper IUDs, this is much more common of a finding with rates up to 20%, while levonorgestrel releasing IUSs have lower rates, around 3%. So it's most likely gonna happen with a copper containing device. Although the progestin releasing family of intrauterine contraceptives is not immune to this. So here's a question and here's where we're going. What do we do with this thing? If we do a liquid based cytology, liquid based pap and everything is just fine. But you find this kind of weird bacteria suggestive of this on a result, what do you do with it? So we're gonna tackle this in two different fronts. Is she asymptomatic, which let me just say right now the vast majority of patients are, or is she symptomatic with some kind of pelvic pain? So we're gonna cover both of those. Now let me, before I even get into the data, we'll give you lots of references here in a minute. Let me just tell you that the quick take Home message here. Absolutely. What everybody fears and what has learned is the actinomyces, pelvic abscesses that are all over the abdomen, she's, you know, potentially very sick. And the treatment is like six months, up to a year, a prolonged antibiotic therapy. As these things clear, all of those are correct. That is, that is absolutely possible. And the treatment is prolonged. Assuming that it really is actinomyces, disseminated pelvic infection and. Or abscesses. I mean, I'm talking about like six months, some say up to a year, to completely eliminate the bacteria from the pelvis. Right. So this is a big deal. However, let me say right here in the intro, the chance that that is actually, actually the case, that this is actually giving the most severe form of manifestation is exceptionally small. Meaning if a patient has pelvic pain and happens to have an IUD and happens to have actinomyces like bacteria seen on that sample, then you absolutely have to work it up. But don't put all of your cards betting that she's probably got pelvic abscesses all over the abdomen. She may, but. But that is exceptionally rare. Whereas other things that are more common, meaning it could be coming from the bladder, it could be coming from the bowel, it could be coming from myofascial sources and. Or other ovarian or uterine issues still has to be investigated. So we're gonna tackle how do we work up the symptomatic patient here and what is considered right now the most diagnostic. All right, so we're gonna talk about histology and microbiology. Histology and microbiology. And just throw in a little snippet of molecular test, which is on the horizon to look for this from an endometrial sample. But most labs don't do that. So histology versus microbiology versus molecular technologies in patients that are symptomatic. Now don't go down a rabbit hole in a patient who has symptoms of some kind of vague pelvic pain just because you see actinomyces, Actinomyces, like bacteria on the sample. Because. And again, I'm giving you all these clinical pearls. I'm even out of the intro yet and I shouldn't do it, but I'm going to do it anyway because these are important things. That is not. If you see that on a, on a liquid based pap or in a traditional Pap, if that's your thing, even though that went out a long time ago. But whatever. If you find actinomyces, like organisms on cytology and the thin prep, a liquid based cytology can find these. That is not diagnostic of infection. Just like trichomoniasis cannot be diagnosed based on liquid based cytology. Even though that's debatable and we've covered that in the past where that's pretty darn sensitive. I mean, if it looks like it, it's gotta be it. But acog, cdc, and even the Infectious Disease Society of America say that it is simply not as sensitive or specific for either trichomoniasis or actinomyces. So to be clear, just because actinomyces is suspected on a cytology result does not make it diagnostic. We're gonna talk about it in this episode, which is another plug. Here it is, guys. Another plug of why potentially primary HPV screening is a thing. Because primary HPV screening is looking for, do you have the DNA signal of high risk hpv and. And if you do, boom, go down that molecular test like a dual stain, which we've talked about, and then you get away from all of this incidental finding. But in this case, because this was found on cytology, which is where this is gonna be found, rather than just doing primary hpv, which is. That's all you're looking for. I'm looking for HPV DNA signals. And that's again another move, another push as to why potentially high risk HPV or HPV primary screening is becoming a preferred option here. Well, I think I've set it up enough. If you can't tell, I'm actually in my home office. We have a home studio and my dog is unbelievably going nuts at somebody walking by. If you didn't hear that, then great, but I'm sure you did. All right, podcast family, we'll be right back talking about what to do with the IUD cytology and and actinomyces. We'll be right back. So good, so good, so good. Give big, save big with RAC Friday deals at Nordstrom Rack. For a limited time, take an extra 40% off red tag clearance for a total Savings up to 75% off. Save on gifts for everyone on your list from brands like Vince Cole, Haan, Sam Edelman and more. All sales final and restrictions apply. The best stuff goes fast. So bring your gift list and and your wish list to your nearest Nordstrom Rack today. Extra value meals are back. That means 10 tender juicy McNuggets and medium fries and a drink are just $8 only at McDonald's for a limited time only. Prices and participation may vary. Prices may be higher In Hawaii, Alaska and California. And for delivery. This is Dr. Choppa's ob gyn no spin podcast. So the term is actinomycetes or actinomyces, which results in actinomycosis. I know it's complicated. What kind of stupid name is that? It's kind of a weird name because it always makes me think of a fungi of yeast, but alas, no, it's bacteria. But it does look like filamentous or branching organisms on stain. And that's why this is something that can be picked up by conventional slide, Pap smear or even on liquid based cytology. However, it's neither sensitive nor specific enough to make a diagnosis. So if you see that on liquid based cytology, go. Oh, well, that's interesting. Thank you very much. Actinomycetes suspected. What kind of stupid name is that? It is a weird name. Actinomycetes suspected. However, that's not enough to make it diagnostic. So if you suspect true infection, then you really have to do some kind of workup. You have to prove that it's there. Similar to trichomoniasis trichomonads seen on liquid based cytology. And I get it. Sometimes things look like one thing. But false positives do exist, false negative exist. So you cannot use a liquid based cytology test for diagnoses of either actinomycosis or trichomoniasis. Though we're not talking about trichomoniasis in this episode. So here's a question. What do we do with this when we find this issue? Find these organisms or things suspicious of these organisms in a patient who is otherwise asymptomatic, has an IUD in place, and more likely would have a copper T rather than a progestin only system. What do we do with this? Well, it's very clear ACOG has guidance on this. So does the Infectious Disease Society of America and the cdc. If they're asymptomatic, you do nothing. You don't take away the iud. You don't go nuts. Go. Oh, interesting. Thank you very much, Pafmir, for your possible actinomycetes finding. What kind of stupid name is that? But that means nothing. We're gonna keep on going. So you leave it in place. And the fear is, well, am I putting her at risk? I mean, she's got this horrible condition called actinomycetes. Am I increasing her chances of getting pelvic inflammatory or upper tract infection? The short answer is nyet. Nada. Nope. It doesn't seem to this has actually been looked at. And in patients who were found to have otherwise asymptomatic actinomycosis, the chance that they actually converted to true infection over a period of six months was about 1.3%, y'. All. Let's just call it what it is. About 1%. About 1%, meaning close to 99%, did nothing. So I don't want to minimize this. Yes, actinomycetes or actinomycosis. The most typical that usually gets its name out there is actinomycosis. Israeli. This is actually possible to. To cause bad things. However, as we said in the intro, this can live in the vagina as an innocent bacteria, more so if patients have an IUD or IUS in place. But stop blaming it for things that it may not have anything to do with. So according to a large cohort study, 1.3% of current IUD wearers developed PID like symptoms after finding these organisms or organism like characteristics or on a cytology. All right, so that's the very good news. Now we do have to tell the patient, hey, your Pap smear maybe found something. It's kind of weird. It's something that we really worry about that much. It's got a weird name. It's called actinomycetes. What kind of stupid name is that? And we just have to know that it's there. But really, there's nothing to do at this time. Just if you feel something's off, just come on in, just let us know. Now, that's the good news. The not so good news is that if a patient really does develop symptomatic infection, I mean, wow. I mean, it's like nothing or like everything. I mean, it causes pelvic pain, it causes some weight loss, it can cause systemic symptoms like fever and chills, and it causes pelvic masses like abscesses. So the chance that they're gonna have something, that this thing's gonna be symptomatic and you not know is gonna be very small. So they will tell you. Relax. They will tell you. In asymptomatic patients, what you do is nothing short of maybe a little message to the patient. The Pap smear or the cytology found something that may or may not be real. I'm not worried about it. It's not a sexually transmitted infection. Just be aware. And it's not unusual for women to have this, especially with an IUD or an IUS in place, and that's the end of that. However, if they are symptomatic with some kind of pelvic pain. Knowing, of course, that it could be a variety of things, you can't ignore that. And that should have some kind of evaluation. And a good place to start without getting real invasive is just a transvaginal ultrasound. Transvaginal ultrasound can and should be used to image the pelvic structures in patients that you suspect this thing may be causing active symptoms. Because ultrasound, of course, is our de facto imaging modality. And if it's negative, it is very reassuring. Right? So let me say that again. If an ultrasound, transvaginal ultrasound is negative, it is highly reassuring. Now, if you find weird pelvic abscesses that look like toas, then you pretty much need to work that up, especially if actinomycetes was found prior to this symptomatology developing. And one of the ways that you can further image the pelvis is either by CT or mri. Now, CT and MRI is not mainstream for regular old street variety of pid, but if you suspect actinomycetes, these abscesses can be distributed outside of the pelvis. So abdominal pelvic CT or mri, it would be necessary not only as a baseline, but if you find multiple abscesses, you need to make sure that they're getting better and or resolved with prolonged therapy. Now, I'm just going to mention at the end what this therapy looks like, because it's a whopper. I mean, thank the Lord that only like 1.3% developed this over the course of half a year and 99% did nothing because it literally is six months to a year of antibiotic therapy for these things to clear. Now, it is rare, now, it is rare that this requires surgical intervention. This is mainly treated either by interventional radiology and doing a kind of a sample of a mass and or drainage, percutaneous drainage. But traditionally this is just a combination of IV and prolonged oral therapy for these things to take away the inflammation and for these things to resolve. The reason it takes so long to treat this is because these are facultative anaerobes and it takes a long time for these things to go away. Okay? So I know that sounds horrible, it sounds frightening, and it is. We should respect prolonged course of therapy in anybody. But thankfully, this is. That is really, really unusual. If you do suspect that actinomycetes is possibly causing harm, then the de facto diagnostic tool is regular old emb. You leave the IUD in place, don't mess with it, just do an endometrial biopsy. Because histopathology guys, historically, histology is the diagnostic quote, gold standard, end quote. And that's directly from the Infectious Disease Society of America, idsa. It's still the best way to go. Now we're gonna talk about three different buckets. Even though this is very fast, we can do histopathology, which I already told you, that's the de facto. That's a check mark. Get an EMB and send that to the pathologist and put in there, this patient has an iud, pelvic pain. And specifically, I want you to look for actinomycities. Right? They have to know some kind of clinical context of what they're looking for. All right, so do that. We're going to talk about culture, and we'll do that next here in just a minute. Although culture. Sure, why not? But even culture's got issues, because these things are facultative anaerobes. And these cultures have to be sealed anaerobically very quickly and cultured in an anaerobic environment for these things to grow. And they could take up to two weeks to see a colony. So culture, while bacteriology and microbiology is typically something we strive for, we like our blood cultures and our urine cultures, and we should. But for this organism, culture really is not the best. Okay, PCR also sounds good. If you could do a molecular assessment. But not all labs offer PCR testing of endometrial tissue. But that obviously would work. But. But because it's not universal in most labs, even the Infectious Disease Society of America doesn't state PCR as an option. It says if you really suspect that it is and all of your other tests are negative, then possibly do PCR with a reference lab. Toast the holidays in a new way, and raise a glass of rumchata, a delicious creamy blend of horchata with rum. Enjoy it over ice cream or in your coffee. Rumchata. Your holiday cocktails just got sweeter. Tap or click the banner for more Drink responsibly. Caribbean rum with real dairy cream. Natural and artificial flavors. Alcohol 13.75% by volume 27.5 proof. Copyright 2025 Agave Logo Brands, Pojoaaukee, Wisconsin. All rights reserved. So back to endometrial biopsy. Endometrial biopsy with histopathological analysis of this thing is nearly always the way that this thing is diagnosed. Extremely high sensitivity and specificity. But your pathologist once again, needs to know exactly what they're looking for. And this is because these organisms leave traces behind. That's where you get these Sulfur granules. Remember that sulfur granules within tissue and the bacteria, at times they may or may not be visible, but they leave behind tissue damage, and that's what they're looking for. So EMB or histology is absolutely the preferred, even over microbiological tests. Let me say that again. EMB histology is preferred over microbiological tests. Cultures got issues, as we already talked about. And then molecular tests, as fancy as they sound, is not yet the standard. Again, I'm gonna say this very quickly and then we're gonna start wrapping this up because it's very short. Actinomycetes is out there. Even though it's got a weird name. What a stupid name is that. Actinomyce is out there. I love that my CDs is out there. But the chance that it causes infection is pretty rare. And even PCR. Again, not referenced as of November 2025, not referenced by the Infectious Disease Society of America at this time, nor by the American Society of Microbiology, because not all labs do it. All right, so it would be great if your lab can figure it out and you've got a reference lab that does pcr. Knock yourself out. But similar to culture, definitely secondary to regular old histology. Very quickly, guys, for treatment, if you suspect that this patient actually has it and or has pelvic masses and or the EMB has histopathological confirmation of this, it is a prolonged course of penicillin. So first thing first, you got to remove the iud. That helps prevent reinfection and helps clear the infection faster because it's considered a seeded foreign body. Okay, so you remove it and then it's a combination of both high dose IV penicillin G, at least initially for about four to six weeks, guys, four to six weeks. And then it's oral penicillin or amoxicillin for a minimum of six months. But it could take up to 12 months, one year of treatment. So as we wrap this up very quickly, expectant management for asymptomatic patients is the way to go. And if you suspect a patient is actively infected and symptomatic from that, then you can do imaging with transvaginal ultrasound as a screen. You can do an endometrial biopsy if there's something suspicious on the ultrasound and or on the biopsy, then proceed to CT or MRI and get ready to for a prolonged course of antibiotics to take care of actinomycetes. What kind of stupid name is that? Podcast family. As always, we're thankful for your messages. We're thankful for your questions because these questions we turn into episodes. Our producer, Michael, is. You think I'm high stress, high energy. Michael, God bless him, he is an Energizer Bunny as well. Although he's actually by voice and by mood, he's very calm. But, man, that guy's a workhorse. He's. Anyway, he's always concerned about, you know, we're run out of stuff to talk about. Never. There's always stuff to talk about, even if there's not stuff that's hot in press or stuff that we're like, meh. The questions that come in are so clinical. Like this one. I told him we're going to cover actinomycosis, and his answer was, as I would expect. What kind of stupid name is that? I'm like, brother, it's a thing. Trust me. It's a bacteria, and it can make women sick. But thankfully, it is really, really rare as a cause of symptomatic infection. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. And now that we've done all that, Michael, let's do it. Should we? Let's take it home. What kind of stupid name is that? We'll see you next time. Foreign. This has been Dr. Chapa Zobi Gyn no Spin podcast Podcast family. Thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin Podcast.