Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is a general term that refers to infection and inflammation of the reproductive organs in women. It may affect the uterus (womb), fallopian tubes (tubes that carry eggs from the ovaries to the uterus), ovaries, and other organs related to reproduction. The scarring that results from infections on these organs can lead to infertility, tubal (ectopic) pregnancy, chronic pelvic pain, abscesses (collections of pus), and other serious problems. PID is the most common preventable cause of infertility in the United States.

In the United States, more than 1 million women seek treatment for acute PID each year, according to the Centers for Disease Control and Prevention (CDC). A similar or greater number of women may have PID and not know it. PID is more common among teenage than adult women. It is also more common among African-American and Hispanic women. Every year, more than 100,000 women become infertile and more than 150 women die from PID or its complications.

Female Reproductive System Source: NCI

Symptoms

PID can have a wide range of presentations. Many women with PID have no symptoms at all, while others have subtle symptoms and still others have severe symptoms. The most common symptom of PID is pain in your lower abdomen. Other symptoms that you may or may not have include

• Fever
• Vaginal discharge that may have an odor
• Painful intercourse
• Painful urination
• Irregular menstrual bleeding
• Low back pain
• Pain in the upper right abdomen (rare)
• Nausea and vomiting (in severe cases)

Sometimes PID comes on suddenly with extreme pain and fever, especially if it is caused by gonorrhea.

PID happens most commonly at the end of a woman's period and for about 10 days following that.

Causes

A scanning electron micrograph (SEM) depicting four views of Gram-negative Neisseria gonorrhoeae bacteria Source:CDC

Most cases of PID are caused by bacteria that cause sexually transmitted infections (STIs) such as chlamydia or gonorrhea. Sometimes the normal bacteria in the vagina can cause PID. Often a mixture of bacteria is responsible.

Diagnosis

Diagnosis of PID is not always easy, because the symptoms can be like those of other diseases. Generally a physical examination, including a pelvic (internal exam), and tests to rule out other possibilities (such as ultrasound are sometimes necessary).

The CDC recommends that, in a sexually active woman at risk for infection who has abdominal pain and tenderness with no other explanation, any of the following three criteria on pelvic exam is enough to merit treatment for possible PID: cervical motion tenderness OR uterine tenderness OR adnexal (ovarian or tubal) tenderness.^[1]

Physical examination

The health care provider presses on the abdomen and performs a pelvic exam to determine what part of the body is tender to the touch. Especially important is examination of the cervix (opening to the uterus), uterus, and fallopian tubes and ovaries. He or she will look for lumps or masses on the fallopian tubes and ovaries, and check for abnormal vaginal or cervical discharge.

Tests

A urine test is done to check for pregnancy and urine infections. Gonorrhea and chlamydia are tested for. Sometimes blood tests are done, especially to see if the white blood cell count is elevated, which is a sign of infection.

Additional tests may be needed to distinguish between PID and other serious problems that can mimic PID. These may include:

• Ultrasound (sonogram)
• CT scan, especially if appendicitis is a possibility
• Laparoscopy: This is a surgical procedure in which a tube is inserted through a small incision near your navel. This allows a surgeon to view the internal abdominal and pelvic organs and to take specimens to examine in the laboratory.

Treatment

PID is caused by bacteria, and is treated by antibiotics. Because more than one type of bacteria can be responsible, a combination of antibiotics is given, either intravenously (through an IV) or by mouth. Treatment needs to start right away to prevent complications.

Other treatments may include pain medications, IV fluids, and antinausea medications.

Even if your symptoms go away, you should finish taking all of the medicine. A full course of treatment lasts two weeks. You also should return to your health care provider 2 to 3 days after beginning the medicine to be sure the antibiotics are working. You should avoid having sex until cured, and avoid douching from now on. You will need to be tested for HIV, and your sex partner should be tested for gonorrhea and chlamydia. You should also discuss ways of preventing PID from happening again.

Most cases of PID can be treated at home. However, women may need to be admitted to the hospital for PID if they:

• Are severely ill
• Are pregnant
• Do not respond to or cannot take oral medicine
• Need intravenous (in the vein) antibiotics
• Have an abscess (swelling) in your fallopian tube or ovary
• Have immune problems (eg, HIV infection with low CD4 counts, immunosuppressive therapy) or another serious disease.

If symptoms continue or if an abscess does not go away, surgery might be necessary.

Prevention

Most cases of PID are preventable. Because gonorrhea and chlamydia cause most cases of PID, preventing them is crucial.

Many women have gonorrhea and chlamydia and don't know it. A very large proportion--up to 45% and 77%, respectively--of gonococcal and chlamydial infections are asymptomatic (without symptoms) in women.^[2] This is why women at risk, such as those with multiple sex partners and those who do not use condoms, should be tested. All sexually active women under age 25 should be screened every year for gonorrhea and chlamydia.^[3] Women older than 25 should in many cases be screened yearly as well. You should get regular laboratory tests for chlamydia, gonorrhea, and if appropriate, pregnancy. Your health care provider may suggest these tests as part of a routine annual exam as well as tests for HIV infection and syphilis.

If these infections are not detected or treated properly, 20 to 40 percent of women with chlamydia and 10 to 40 percent of women with gonorrhea may develop PID.

The surest way to avoid getting or transmitting sexually transmitted infections (STIs) is to abstain from sex or to be in a long-term, mutually monogamous relationship with a partner who has been tested and isn't infected. Condoms, when used consistently and correctly, can reduce your risk of getting chlamydia and gonorrhea.^[4]

In addition, a woman can protect herself from PID by getting treated quickly if she does get an STI, or getting checked right away if she has unprotected sex with a partner who might have an STI.

Chances of Developing Pelvic Inflammatory Disease

Risk factors

Several things place a woman at greater risk of PID:

• Young age: The cervix (opening to the uterus) of teens and young women has greater susceptibility to STIs.
• Sexual practices: a woman with many sex partners or a single infected sex partner is at risk. Not using a condom increases the risk, as it allows bacteria to travel between partners.
• Douching: Douching may increase the risk of PID, as it changes the normal bacteria of the vagina and may force harmful bacteria through the cervix. Douching is a risky practice and should generally be avoided.
• IUD: An intrauterine device (IUD) to prevent pregancy may increase the risk of PID, but this risk is much reduced if a woman is checked and treated for STIs before the IUD is put in.^[5]
• Previous PID: PID may heal with scarring of the reproductive organs, which are then more susceptible to infection in the future. The more a woman gets PID, the more likely she may be to get it again.
• Rarely, PID results from gynecological procedures or surgeries.

Related Problems

PID can cause permanent damage to the female reproductive organs. Infection-causing bacteria can silently invade the fallopian tubes, causing normal tissue to turn into scar tissue. This scar tissue blocks or interrupts the normal movement of eggs into the uterus. If your fallopian tubes are totally blocked by scar tissue, sperm cannot fertilize an egg and you become infertile. Infertility also can occur if the fallopian tubes are partially blocked or even slightly damaged. About one in five women with PID becomes infertile.

In addition, a partially blocked or slightly damaged fallopian tube may cause a fertilized egg to remain in the fallopian tube. If this fertilized egg begins to grow in the tube as if it were in the uterus, it is called an ectopic or tubal pregnancy. An ectopic pregnancy can rupture the fallopian tube, causing severe pain, internal bleeding, and even death.

Scarring in the fallopian tubes and other pelvic organs can also cause chronic pelvic pain (pain lasting for months or even years). You are more likely to suffer infertility (20 percent of women), ectopic pregnancy (9 percent), or chronic pelvic pain (18 percent) if you have repeated episodes of PID.

Complications of PID such as chronic pelvic pain and scarring are difficult to treat, but sometimes they improve with surgery.

Clinical Trials

For a list of completed, ongoing, and upcoming clinical trials related to PID, go to Pelvic Inflammatory Disease Trials .

Research

Although scientists have learned much about the biology of the microbes (germs) that cause PID and the ways in which they damage the body, they still have much to learn. Scientists supported by the National Institute of Allergy and Infectious Diseases (NIAID) are studying the effects of antibiotics, hormones, and substances that boost the immune system. These studies may lead to insights about how to prevent infertility and other complications of PID.

Scientists are developing rapid, inexpensive, and easy-to-use diagnostic tests to detect chlamydia and gonorrhea.

Researchers also are developing topical microbicides and vaccines that prevent gonorrhea and chlamydia. Others are investigating whether additional microbes such as Mycoplasma genitalium cause PID and are developing diagnostic tests and treatments for this infection. Meanwhile, researchers continue to search for better ways to detect PID, particularly in women who have no symptoms.

Expected Outcome

The prognosis is good if the disease is diagnosed and treated early. However, if risky behaviors continue, the chances of getting PID again are high.

References

1. ↑ CDC. Sexually Transmitted Diseases Treatment Guidelines 2006
2. ↑ Farley TA, Cohen DA, Elkins W. Asymptomatic sexually transmitted diseases: The case for screening. Prev Med 2003;36:502.Full Text
3. ↑ Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2002. MMWR 2002;51(No.RR-6):1.
4. ↑ Ness RB, Randall H, Richter HE, et al. Pelvic Inflammatory Disease Evaluation and Clinical Health Study Investigators. Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease. Am J Public Health. 2004 Aug;94(8):1327-9. Abstract
5. ↑ Mohllajee AP, Curtis KM, Peterson HB. Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review. Contraception. 73(2):145-53, 2006 Feb. Abstract

External Links

Centers for Disease Control: PID

eMedicine Health: PID

Mayo Clinic: Pelvic inflammatory Disease

American Social Health Association: PID