Pelvic Inflammatory Disease
Aside from AIDS, the most common and serious complication of
sexually transmitted diseases (STDs) among women is pelvic
inflammatory disease (PID), an infection of the upper genital tract.
PID can affect the uterus, ovaries, fallopian tubes, or other
related structures. Untreated, PID causes scarring and can lead to
infertility, tubal pregnancy, chronic pelvic pain, and other serious
consequences.
Each year in the United States, more than 1 million women
experience an episode of acute PID, with the rate of infection
highest among teenagers. More than 100,000 women become infertile
each year as a result of PID, and a large proportion of the 70,000
ectopic (tubal) pregnancies occurring every year are due to the
consequences of PID. In 1997 alone, an estimated $7 billion was
spent on PID and its complications.
Cause
PID occurs when disease-causing organisms migrate upward from
the urethra and cervix into the upper genital tract. Many
different organisms can cause PID, but most cases are associated
with gonorrhea and genital chlamydial infections, two very common
STDs. Scientists have found that bacteria normally present in
small numbers in the vagina and cervix also may play a role.
Investigators are learning more about how these organisms cause
PID. The gonococcus, Neisseria gonorrhea, probably travels
to the fallopian tubes, where it causes sloughing (casting out) of
some cells and invades others. Researchers think it multiplies
within and beneath these cells. The infection then may spread to
other organs, resulting in more inflammation and scarring.
Chlamydia trachomatis and other bacteria may behave in a
similar manner. Researchers do not know how other bacteria that
normally inhabit the vagina (e.g., organisms such as
Gardnerella vaginalis and Bacteroides) gain entrance
into the upper genital tract. The cervical mucus plug and
secretions may help prevent the spread of microorganisms to the
upper genital tract, but it may be less effective during ovulation
and menses. In addition, the gonococcus may gain access more
easily during menses, if menstrual blood flows backward from the
uterus into the fallopian tubes, carrying the organisms with it.
This may explain why symptoms of PID caused by gonorrhea often
begin immediately after menstruation as opposed to any other time
during the menstrual cycle. It is noteworthy that the co-incidence
of menses and chlamydial infection is not a prominent feature of
chlamydial PID.
Symptoms
The major symptoms of PID are lower abdominal pain and abnormal
vaginal discharge. Other symptoms such as fever, pain in the right
upper abdomen, painful intercourse, and irregular menstrual
bleeding can occur as well. PID, particularly when caused by
chlamydial infection, may produce only minor symptoms or no
symptoms at all, even though it can seriously damage the
reproductive organs.
Risk Factors for PID
- Women with STDs – especially gonorrhea and chlamydial
infection – are at greater risk of developing PID; a prior
episode of PID increases the risk of another episode because the
body’s defenses are often damaged during the initial bout of
upper genital tract infection.
- Sexually active teenagers are more likely to develop PID
than are older women.
- The more sexual partners a woman has, the greater her risk
of developing PID.
Recent data indicate that women who douche once or twice a
month may be more likely to have PID than those who douche less
than once a month. Douching may push bacteria into the upper
genital tract. Douching also may ease discharge caused by an
infection, so the woman delays seeking health care.
Diagnosis
PID can be difficult to diagnose. If symptoms such as lower
abdominal pain are present, the doctor will perform a physical
exam to determine the nature and location of the pain. The doctor
also should check the patient for fever, abnormal vaginal or
cervical discharge, and evidence of cervical chlamydial infection
or gonorrhea. If the findings of this exam suggest that PID is
likely, current guidelines advise doctors to begin treatment.
If more information is necessary, the doctor may order other
tests, such as a sonogram, endometrial biopsy, or laparoscopy to
distinguish between PID and other serious problems that may mimic
PID. Laparoscopy is a surgical procedure in which a tiny, flexible
tube with a lighted end is inserted through a small incision just
below the navel. This procedure allows the doctor to view the
internal abdominal and pelvic organs, as well as take specimens
for cultures or microscopic studies, if necessary.
Treatment
Because culture of specimens from the upper genital tract are
difficult to obtain and because multiple organisms may be
responsible for an episode of PID, especially if it is not the
first one, the doctor will prescribe at least two antibiotics that
are effective against a wide range of infectious agents. The
symptoms may go away before the infection is cured. Even if
symptoms do go away, patients should finish taking all of the
medicine. Patients should be re-evaluated by their physicians two
to three days after treatment is begun to be sure the antibiotics
are working to cure the infection.
About one-fourth of women with suspected PID must be
hospitalized. The doctor may recommend this if the patient is
severely ill; if she cannot take oral medication and needs
intravenous antibiotics; if she is pregnant or is an adolescent;
if the diagnosis is uncertain and may include an abdominal
emergency such as appendicitis; or if she is infected with HIV
(human immunodeficiency virus, the virus that causes AIDS).
Many women with PID have sex partners who have no symptoms,
although their sex partners may be infected with organisms that
can cause PID. Because of the risk of reinfection, however, sex
partners should be treated even if they do not have symptoms.
Consequences of PID
Women with recurrent episodes of PID are more likely than women
with a single episode to suffer scarring of the tubes that leads
to infertility, tubal pregnancy, or chronic pelvic pain.
Infertility occurs in approximately 20 percent of women who have
had PID.
Most women with tubal infertility, however, never have had
symptoms of PID. Organisms such as C. trachomatis can
silently invade the fallopian tubes and cause scarring, which
blocks the normal passage of eggs into the uterus.
A women who has had PID has a six-to-tenfold increased risk of
tubal pregnancy, in which the egg can become fertilized but cannot
pass into the uterus to grow. Instead, the egg usually attaches in
the fallopian tube, which connects the ovary to the uterus. The
fertilized egg cannot grow normally in the fallopian tube. This
type of pregnancy is life-threatening to the mother, and almost
always fatal to her fetus. It is the leading cause of
pregnancy-related death in African-American women.
In addition, untreated PID can cause chronic pelvic pain and
scarring in about 20 percent of patients. These conditions are
difficult to treat but are sometimes improved with surgery.
Another complication of PID is the risk of repeated attacks of
PID. As many as one-third of women who have had PID will have the
disease at least one more time. With each episode of reinfection,
the risk of infertility is increased.
Prevention
Women can play an active role in protecting themselves from PID
by taking the following steps:
- Signs of discharge with odor or bleeding between cycles
could mean infection. Early treatment may prevent the
development of PID.
- If used correctly and consistently, male latex condoms will
prevent transmission of gonorrhea and partially protect against
chlamydial infection.
Keeping on Top of Your Condition
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