Pelvic inflammatory disease

Definition

Pelvic inflammatory disease (PID) is a term used to describe any infection in the lower female reproductive tract that spreads upward to the upper female reproductive tract. The lower female genital tract consists of the vagina and the cervix. The upper female genital tract consists of the body of the uterus, the fallopian or uterine tubes, and the ovaries.

Description

PID is the most common and the most serious consequence of infection with sexually transmitted diseases (STD) in women. Over one million cases of PID are diagnosed annually in the United States, and it is the most common cause for hospitalization of reproductive-age women. Sexually active women aged 15–25 are at highest risk for developing PID. The disease can also occur, although less frequently, in women having monogamous sexual relationships. The most serious consequences of PID are increased risk of infertility and ectopic pregnancy .

To understand PID, it is helpful to understand the basics of inflammation. Inflammation is the body's response to disease-causing (pathogenic) microorganisms. The affected body part may swell due to accumulation of fluid in the tissue or may become reddened due to an excessive accumulation of blood. A discharge (pus) may be produced that consists of white blood cells and dead tissue. Following inflammation, scar tissue may form by the proliferation of scar-forming cells (fibrosis). Adhesions of fibrous tissue form and cause organs or parts of organs to stick together.

PID may be used synonymously with the following terms:

• salpingitis (inflammation of the fallopian tubes)
• endometritis iInflammation of the inside lining of the body of the uterus)
• tubo-ovarian abscesses (abscesses in the tubes and ovaries)
• pelvic peritonitis (inflammation inside of the abdominal cavity surrounding the female reproductive organs)

Causes & symptoms

A number of factors affect the risk of developing PID. They include:

• Age. The incidence of PID is very high in younger women and decreases as a woman ages.
• Race. The incidence of PID is 8–10 times higher in nonwhites than in whites.
• Socioeconomic status. The higher incidence of PID in women of lower socioeconomic status is due in part to a woman's lack of education and awareness of health and disease, and due in part to barriers to her accessibility to medical care.
• Use and method of contraception. Induced abortion, use of an IUD, nonuse of such barrier contraceptives as condoms, and frequent douching are all associated with a higher risk of developing PID.
• Lifestyle.Such high-risk behaviors as drug and alcohol abuse; early age at first intercourse; a high number of sexual partners; and smoking all are associated with a higher risk of developing PID.
• Specific sexual practices. Intercourse during the menses and frequent intercourse may offer more opportunities for the admission of pathogenic organisms to the inside of the uterus.
• The presence of a sexually transmitted disease. Sixty to seventy-five percent of PID cases are associated with STDs. A prior episode of PID increases the chances of developing subsequent infections .

The two major organisms that cause STDs are Neisseria gonorrhoeae and Chlamydia trachomatis. The main symptom of N. gonorrheae infection (gonorrhea ) is a vaginal discharge of mucus and pus. Sometimes bacteria from the colon normally in the vaginal cavity may travel upward to infect the upper female genital organs, facilitated by the infection with gonorrhea. Infections with C. trachomatis and other nongonoccal organisms are more likely to have mild or no symptoms.

Although PID is unusual in women who are not sexually active, disease organisms other than the gonococcus and C. trachomatis can occasionally gain entrance to the upper female reproductive tract and cause PID. Cases have been reported from Canada, Norway, and South America of PID caused by pinworms, pneumococci, and Entamoeba histolytica, a pathogenic amoeba.

Normally the cervix produces mucus that acts as a barrier to prevent disease-causing microorganisms, called pathogens, from entering the uterus and moving upward to the tubes and ovaries. This barrier may be breached in two ways. A sexually transmitted pathogen, usually a single organism, invades the lining cells, alters them, and gains entry. Another way for organisms to gain entry happens when trauma or alteration to the cervix occurs. Childbirth , spontaneous or induced abortion, or use of an intrauterine contraceptive device (IUD) are all conditions that may alter or weaken the normal lining cells, making them susceptible to infection, usually by several organisms. During menstruation , the cervix widens and may allow pathogens entry into the uterine cavity.

Recent evidence suggests that bacterial vaginosis (BV), a bacterial infection of the vagina, may be associated with PID. BV results from the imbalance of normal organisms in the vagina—by douching, for example. While the balance is altered, conditions then favor the overgrowth of anaerobic bacteria that thrive in the absence of free oxygen. A copious discharge is usually present. Should some trauma occur in the presence of anaerobic bacteria, such as menses, abortion, intercourse, or childbirth , these organisms may gain entrance to the upper genital organs.

The most common symptom of PID is pelvic pain . However, many women with PID have symptoms so mild that they may be unaware that they are infected.

In acute salpingitis, a common form of PID, swelling of the fallopian tubes may cause tenderness on physical examination. Fever may be present. Abscesses may develop in the tubes, ovaries, or in the surrounding pelvic cavity. Infectious discharge may leak into the peritoneal cavity and cause peritonitis; or abscesses may rupture, causing a life-threatening surgical emergency.

Chronic salpingitis may follow an acute attack. Subsequent to inflammation, scarring and resulting adhesions may result in chronic pain and irregular menses. Due to blockage of the tubes by scar tissue, women with chronic salpingitis suffer a high risk of having an ectopic pregnancy. An ectopic pregnancy develops when a fertilized ovum is unable to travel down the fallopian tube to the uterus and implants itself in the tube, on the ovary, or in the peritoneal cavity. This condition can also be a life-threatening surgical emergency.

IUDs

The use of intrauterine devices, or IUDs, has been strongly associated with the development of PID. Bacteria may be introduced to the uterine cavity while the IUD is being inserted or may travel up the tail of the IUD from the cervix into the uterus. Surrounding uterine tissue may show areas of inflammation, increasing its susceptibility to pathogens.

Some researchers, however, maintain that the connection between IUDs and PID has been exaggerated and that further research is necessary.

Susceptibility to STDs

Susceptibility to STDs involves many factors, some of which are not known. The ability of the organism to produce disease and the circumstances that place the organism in the right place at a time when a trauma or alteration to the lining cells has occurred are factors. The woman's own immune response also helps to determine whether infection occurs.

Diagnosis

If PID is suspected, the physician will take a complete medical history and perform an internal pelvic examination. Other diseases that may cause pelvic pain, such as appendicitis and endometriosis , must be ruled out. If pelvic examination reveals tenderness or pain in that region, or tenderness on movement of the cervix, these are good physical signs that PID is present.

Specific diagnosis of PID is difficult to make because the upper pelvic organs are hard to reach for samplings. The physician may take samples directly from the cervix to identify the organisms that may be responsible for infection. Two blood tests may help to establish the existence of an inflammatory process. A positive C-reactive protein (CRP) and an elevated erythrocyte sedimentation rate (ESR) indicate the presence of inflammation. The physician may take fluid from the cavity surrounding the ovaries called the cul de sac ; this fluid may be examined directly for bacteria or may be used for culture. Diagnosis of PID may also be done using a laparoscope, but laparoscopy is expensive, and it is an invasive procedure that carries some risk for the patient.

A newer diagnostic technique that has dramatically improved the accuracy of laboratory testing for PID and other STDs is the ligase chain reaction (LCR) technique. The LCR technique detects DNA from N. gonorrhoeae and C. trachomatis in a patient's urine sample. LCR technology is less invasive as well as more accurate.

Treatment

Alternative therapy should be complementary to antibiotic therapy. Because of the potentially serious nature of this disease, a patient should first consult an allopathic physician to start antibiotic treatment for infections. Traditional medicine is better equipped to quickly eradicate the infection, while alternative treatments can help the body fight the disease and relieve painful symptoms associated with PID. Some of the alternative treatments include diets , nutritional supplements, herbal remedies, homeopathy, acupressure , and acupuncture .

General recommendations

• Bed rest. Patients need to rest and reduce physical activity to help the body recuperate faster.
• Avoid sexual activity. Both patient and her partner should be treated for PID infections. They should also avoid sexual activity until their infections are completely eradicated.
• Healthy diet. Diet should include a variety of fresh fruits and vegetables. These foods contain high amount of phytonutrients and essential vitamins that help keep the body strong and stimulate the immune system to fight infections.

Nutritional supplements

The following nutritional supplements may be helpful:

• Daily vitamin and mineral supplements. These supplements can ensure that the body receives all the essential nutrients for normal body function. They also help keep the body strong to fight diseases including PID.
• Vitamin C . High-dose vitamin C (1–2 g) boost the immune function and help the body fight infection better.

Herbal treatment

The following herbal remedies may be helpful:

• Castor oil packs. Patients can make warm packs by pouring castor oil on a clean piece of cloth wrapped in layers and warming it before placing on the lower part of their abdomen for up to 20 minutes. It is recommended that patients repeat this therapy every day for up to seven days.
• Echinacea spp., goldenseals and Calendula officinalis. These herbs are believed to have antimicrobial activity and may be taken to augment the action of prescribed antibiotics.
• Grapefruit seed extract. This herb has been used to fight a variety of infections including bacterial, viral, fungal, parasitic, and worm infections.
• Blue cohosh (Caulophyllum thalictroides ) and false unicorn root (Chamaelirium luteum ). These remedies are recommended as tonics for the general well-being of the female genital tract.

Homeopathy

A homeopathic practitioner may prescribe a patient-specific remedy to help reduce some of the symptoms associated with PID. Herbs that are used in PID patients include Apis mellifica, Arsenicum album, Belladonna , Colocynthis, Magnesia phosphorica, and Mercurius vivus.

Acupressure

Acupressure (applying pressure on specific pressure points) can increase blood flow to the pelvic region, reduce pain, and promote general health.

Acupuncture

Acupuncture involves inserting needles at various points on the skin of the body. These needles are like antennae that direct qi (life force) to organs or functions of the body. This treatment may help with pain and also strengthen immunity. It is important that patients request disposable needles to prevent transmission of AIDS, hepatitis , and other infectious diseases.

Allopathic treatment

If acute salpingitis is suspected, treatment with antibiotics should begin immediately. The patient is usually treated with at least two broad-spectrum antibiotics that can kill both N. gonorrhoeae and C. trachomatis plus other types of bacteria that may have the potential to cause infection. Hospitalization may be required to ensure compliance. Treatment for chronic PID may involve hysterectomy. Early treatment of suspected PID is essential because some strains of N. gonorrhoeae are showing increasing resistance to standard antibiotics as of 2002.

If a woman is diagnosed with PID, she should see that her sexual partner is also treated to prevent the possibility of reinfection.

Expected results

PID can be cured if the initial infection is treated immediately. If infection is not recognized, as frequently happens, the process of tissue destruction and scarring that results from inflammation of the tubes results in irreversible changes in the tube structure that cannot be restored to normal. Subsequent bouts of PID increase a woman's risk of complications. Thirty to forty percent of female infertility cases are due to acute salpingitis.

With modern antibiotic therapy, death from PID is almost nonexistent. In rare instances, death may occur from the rupture of tubo-ovarian abscesses and the resulting infection in the abdominal cavity. One recent study has linked infertility, a consequence of PID, with a higher risk of ovarian cancer .

Prevention

The prevention of PID is a direct result of the prevention and prompt recognition and treatment of STDs or of any suspected infection involving the female genital tract. The main symptom of infection is an abnormal discharge. To distinguish an abnormal discharge from the mild fluctuations of normal discharge associated with the menstrual cycle takes vigilance and self-awareness. Sexually active women must be able to detect symptoms of lower genital tract disease. Frank dialogue regarding sexual history, risks for PID, and treatment options is necessary with a physician. Also, open discussions with sexual partners regarding symptoms and possible infection is imperative.

Lifestyle changes should focus on preventing the transfer of organisms when the body's delicate lining cells are unprotected or compromised. Barrier contraceptives, such as condoms, diaphragms, and cervical caps, should be used. Women in monogamous relationships should use barrier contraceptives during menses and take their physician's advice regarding intercourse following abortion, childbirth, or biopsy procedures.

Resources

BOOKS

Buhner, Stephen Harrod. Herbal Antibiotics: Natural Alternatives for Treatment of Drug-Resistant Bacteria. Pownal, VT: Schoolhouse Road, 1999.

Kurman, Robert J., ed. Blaustein's Pathology of the Female Genital Tract. New York: Springer-Verlag, 1994.

Landers, D.V., and R. L. Sweet, eds. Pelvic Inflammatory Disease. New York: Springer, 1997.

The PDR Family Guide to Natural Medicine and Herbal Therapies: The Most Comprehensive Book of Its Kind. New York, NY: Three Rivers Press, 1999.

Zand, Janet, Allan N. Spreen and James B. LaValle. "Pelvic Inflammatory Disease." In Smart Medicine for Healthier Living: A Practical A-to-Z Reference to Natural and Conventional Treatments for Adults. Garden City Park, NY: Avery Publishing Group, 1999: 467-469.

PERIODICALS

Bucher, A., and F. Muller. "Spectrum of Abdominal and Pelvic Infections Caused by Pneumococci in Previously Healthy Adult Women." European Journal of Clinical Microbiology and Infectious Diseases 21 (June 2002): 474-477.

Calore, E. E., N. M. Calore, and M. J. Cavaliere. "Salpingitis Due to Entamoeba histolytica." Brazilian Journal of Infectious Diseases 6 (April 2002): 97-99.

Centers for Disease Control and Prevention. "Sexually Transmitted Diseases Treatment Guidelines 2002." Morbidity and Mortality Weekly Report 51 (May 10, 2002)(RR-6): 1-78.

Espey, E., and T. Ogburn. "Perpetuating Negative Attitudes About the Intrauterine Device: Textbooks Lag Behind the Evidence." Contraception 65 (June 2002): 389-395.

Kissin, D. M., S. Holman, H. L. Minkoff, et al. "Epidemiology and Natural History of Ligase Chain Reaction Detected Chlamydial and Gonococcal Infections." Sexually Transmitted Infections 78 (June 2002): 208-209.

Tandan, T., et al. "Pelvic Inflammatory Disease Associated with Enterobius vermicularis." Archives of Diseases of Childhood 86 (June 2002): 439-440.

ORGANIZATIONS

American College of Obstetricians and Gynecologists (ACOG). 409 12th St., S.W., PO Box 96920, Washington, D.C. 20090-6920. <www.acog.org>.

Centers for Disease Control and Prevention (CDC). 1600 Clifton Road, Atlanta, GA 30333. (404) 639-3311. <www.cdc.gov>.

Mai Tran

Rebecca J. Frey, PhD

Pelvic Inflammatory Disease

Definition

Pelvic inflammatory disease (PID) is a term used to describe any infection in the lower female reproductive tract that spreads to the upper female reproductive tract. The lower female genital tract consists of the vagina and the cervix. The upper female genital tract consists of the body of the uterus, the fallopian or uterine tubes, and the ovaries.

Description

PID is the most common and the most serious consequence of infection with sexually transmitted diseases (STD) in women. Over one million cases of PID are diagnosed annually in the United States, and it is the most common cause for hospitalization of reproductive-age women. Sexually active women aged 15-25 are at highest risk for developing PID. The disease can also occur, although less frequently, in women having monogamous sexual relationships. The most serious consequences of PID are increased risk of infertility and ectopic pregnancy.

To understand PID, it is helpful to understand the basics of inflammation. Inflammation is the body's response to disease-causing (pathogenic) microorganisms. The affected body part may swell due to accumulation of fluid in the tissue or may become reddened due to an excessive accumulation of blood. A discharge (pus) may be produced that consists of white blood cells and dead tissue. Following inflammation, scar tissue may form by the proliferation of scar-forming cells and is called fibrosis. Adhesions of fibrous tissue form and cause organs or parts of organs to stick together.

PID may be used synonymously with the following terms:

• salpingitis (Inflammation of the fallopian tubes)
• endometritis (Inflammation of the inside lining of the body of the uterus)
• tubo-ovarian abscesses (Abscesses in the tubes and ovaries)
• pelvic peritonitis (Inflammation inside of the abdominal cavity surrounding the female reproductive organs)

Causes and symptoms

A number of factors affect the risk of developing PID. They include:

• Age. The incidence of PID is very high in younger women and decreases as a woman ages.
• Race. The incidence of PID is 8-10 times higher in nonwhites than in whites.
• Socioeconomic status. The higher incidence of PID in women of lower socioeconomic status is due in part to a woman's lack of education and awareness of health and disease and her accessibility to medical care.
• Contraception. Induced abortion, use of an IUD, non-use of barrier contraceptives such as condoms, and frequent douching are all associated with a higher risk of developing PID.
• Lifestyle. High risk behaviors, such as drug and alcohol abuse, early age of first intercourse, number of sexual partners, and smoking all are associated with a higher risk of developing PID.
• Types of sexual practices. Intercourse during menses and frequent intercourse may offer more opportunities for the admission of pathogenic organisms to the inside of the uterus.
• Disease. Sixty to 75% of cases of PID are associated with STDs. A prior episode of PID increases the chances of developing subsequent infections.

The two major causes of STDs are the organisms Neisseria gonorrhoeae and Chlamydia trachomatis. The main symptom of N. gonorrheae infection (gonorrhea ) is a vaginal discharge of mucus and pus. Sometimes bacteria from the colon normally in the vaginal cavity may travel upward to infect the upper female genital organs, facilitated by the infection with gonorrhea. Infections with C. trachomatis and other nongonoccal organisms are more likely to have mild or no symptoms.

Normally, the cervix produces mucus which acts as a barrier to prevent disease-causing microorganisms, called pathogens, from entering the uterus and moving upward to the tubes and ovaries. This barrier may be breached in two ways. A sexually transmitted pathogen, usually a single organism, invades the lining cells, alters them, and gains entry. Another way for organisms to gain entry happens when trauma or alteration to the cervix occurs. Childbirth, spontaneous or induced abortion, or use of an intrauterine contraceptive device (IUD) are all conditions that may alter or weaken the normal lining cells, making them susceptible to infection, usually by several organisms. During menstruation, the cervix widens and may allow pathogens entry into the uterine cavity.

Recent evidence suggests that bacterial vaginosis (BV), a bacterial infection of the vagina, may be associated with PID. BV results from the alteration of the balance of normal organisms in the vagina, by douching, for example. While the balance is altered, conditions are formed that favor the overgrowth of anaerobic bacteria, which thrive in the absence of free oxygen. A copious discharge is usually present. Should some trauma occur in the presence of anaerobic bacteria, such as menses, abortion, intercourse, or childbirth, these organisms may gain entrance to the upper genital organs.

The most common symptom of PID is pelvic pain. However, many women with PID have symptoms so mild that they may be unaware that an infection exists.

In acute salpingitis, a common form of PID, swelling of the fallopian tubes may cause tenderness on physical examination. Fever may be present. Abscesses may develop in the tubes, ovaries, or in the surrounding pelvic cavity. Infectious discharge may leak into the peritoneal cavity and cause peritonitis, or abscesses may rupture causing a life-threatening surgical emergency.

Chronic salpingitis may follow an acute attack. Subsequent to inflammation, scarring and resulting adhesions may result in chronic pain and irregular menses. Due to blockage of the tubes by scar tissue, women with chronic salpingitis are at high risk of having an ectopic pregnancy. The fertilized ovum is unable to travel down the fallopian tube to the uterus and implants itself in the tube, on the ovary, or in the peritoneal cavity. This condition can also be a life-threatening surgical emergency.

IUD

IUD usage has been strongly associated with the development of PID. Bacteria may be introduced to the uterine cavity while the IUD is being inserted or may travel up the tail of the IUD from the cervix into the uterus. Uterine tissue in association with the IUD shows areas of inflammation that may increase its susceptibility to pathogens.

Susceptibility to STDs

Susceptibility to STDs involves many factors, some of which are not known. The ability of the organism to produce disease and the circumstances that place the organism in the right place at a time when a trauma or alteration to the lining cells has occurred are factors. The individual's own immune response also helps to determine whether infection occurs.

Diagnosis

If PID is suspected, the physician will take a complete medical history and perform an internal pelvic examination. Other diseases that may cause pelvic pain, such as appendicitis and endometriosis, must be ruled out. If pelvic examination reveals tenderness or pain in that region, or tenderness on movement of the cervix, these are good physical signs that PID is present.

Specific diagnosis of PID is difficult to make because the upper pelvic organs are hard to reach for samplings. The physician may take samples directly from the cervix to identify the organisms that may be responsible for infection. Two blood tests may help to establish the existence of an inflammatory process. A positive C-reactive protein (CRP) and an elevated erythrocyte sedimentation rate (ESR) indicate the presence of inflammation. The physician may take fluid from the cavity surrounding the ovaries called the cul de sac ; this fluid may be examined directly for bacteria or may be used for culture. Diagnosis of PID may also be done using a laparoscope, but laparoscopy is expensive, and it is an invasive procedure that carries some risk for the patient.

Treatment

The goals of treatment are to reduce or eliminate the clinical symptoms and abnormal physical findings, to get rid of the microorganisms, and to prevent long term consequences such as infertility and the possibility of ectopic pregnancy. If acute salpingitis is suspected, treatment with antibiotics should begin immediately. Early intervention is crucial to keep the fallopian tubes undamaged. The patient is usually treated with at least two broad spectrum antibiotics that can kill both N. gonorrhoeae and C. trachomatis plus other types of bacteria that may have the potential to cause infection. Hospitalization may be required to ensure compliance. Treatment for chronic PID may involve hysterectomy, which may be helpful in some cases.

If a woman is diagnosed with PID, she should see that her sexual partner is also treated to prevent the possibility of reinfection.

Alternative treatment

Alternative therapy should be complementary to antibiotic therapy. For pain relief, an experienced practitioner may apply castor oil packs, or use acupressure or acupuncture. Some herbs, such as Echinacea (Echinacea spp.) and calendula (Calendula officinalis ) are believed to have antimicrobial activity and may be taken to augment the action of prescribed antibiotics. General tonic herbs, as well as good nutrition and rest, are important in recovery and strengthening after an episode of PID. Blue cohosh (Caulophyllum thalictroides ) and false unicorn root (Chamaelirium luteum ) are recommended as tonics for the general well-being of the female genital tract.

Prognosis

PID can be cured if the initial infection is treated immediately. If infection is not recognized, as frequently happens, the process of tissue destruction and scarring that results from inflammation of the tubes results in irreversible changes in the tube structure that cannot be restored to normal. Subsequent bouts of PID increase a woman's risks manyfold. Thirty to forty percent of cases of female infertility are due to acute salpingitis.

With modern antibiotic therapy, death from PID is almost nonexistent. In rare instances, death may occur from the rupture of tubo-ovarian abscesses and the resulting infection in the abdominal cavity. One recent study has linked infertility, a consequence of PID, with a higher risk of ovarian cancer.

Prevention

The prevention of PID is a direct result of the prevention and prompt recognition and treatment of STDs or of any suspected infection involving the female genital tract. The main symptom of infection is an abnormal discharge. To distinguish an abnormal discharge from the mild fluctuations of normal discharge associated with the menstrual cycle takes vigilance and self-awareness. Sexually active women must be able to detect symptoms of lower genital tract disease. Ideally these women will be able to have a frank dialogue regarding their sexual history, risks for PID, and treatment options with their physicians. Also, these women should have open discussions with their sexual partners regarding disclosure of significant symptoms of possible infection.

Lifestyle changes should be geared to preventing the transfer of organisms when the body's delicate lining cells are unprotected or compromised. Barrier contraceptives, such as condoms, diaphragms, and cervical caps should be used. Women in monogamous relationships should use barrier contraceptives during menses and take their physician's advice regarding intercourse following abortion, childbirth, or biopsy procedures.

Resources

BOOKS

Landers, D. V., and R. L. Sweet, editors. Pelvic Inflammatory Disease. New York: Springer, 1997.

KEY TERMS

Adhesion— The joining or sticking together of parts of an organ that are not normally joined together.

C-reactive protein (CRP)— A protein present in blood serum in various abnormal states, like inflammation.

Ectopic— Located away from normal position; ectopic pregnancy results in the attachment and growth of the fertilized egg outside of the uterus, a life-threatening condition.

Endometriosis— The presence and growth of functioning endometrial tissue in places other than the uterus; often results in severe pain and infertility.

Erythrocyte sedimentation rate (ESR)— The rate at which red blood cells settle out in a tube of unclotted blood, expressed in millimeters per hour; elevated sedimentation rates indicate the presence of inflammation.

Fibrosis— The formation of fibrous, or scar, tissue which may follow inflammation and destruction of normal tissue.

Hysterectomy— Surgical removal of the uterus.

Laparoscope— A thin flexible tube with a light on the endthat is used to examine the inside of the abdomen; the tube is inserted into the abdomen by way of a small incision just below the navel.

PELVIC INFLAMMATORY DISEASE (PID)

Pelvic inflammatory disease (PID) refers to infection of the fallopian tubes and other internal reproductive organs in women. It is a common and serious complication of some sexually transmitted diseases (STDs). Douching and using an intrauterine device (IUD) are also associated with increased risk of PID. PID can damage the fallopian tubes and tissues in and near the uterus and ovaries. Untreated, PID can lead to infertility, ectopic pregnancy, and chronic pelvic pain. Each year, more than 1 million U.S. women experience an episode of acute PID. More than 100,000 women become infertile each year as a result of PID, and a large proportion of ectopic pregnancies are due to the consequences of PID. Most cases of PID are associated with gonorrhea and chlamydia; 10 to 20 percent of women with these STDs will develop PID.

PID occurs when bacteria move upward from a woman's vagina or cervix into the internal reproductive organs. Bacteria can silently invade the fallopian tubes and cause scarring that blocks or interrupts the normal movement of eggs into the uterus. Because many women have only vague or mild symptoms, PID frequently goes unrecognized. Women who do have symptoms commonly have pain in the lower or right upper abdomen, fever, unusual vaginal discharge, painful intercourse, and irregular menstrual bleeding. PID can be cured with antibiotics. Women with pelvic pain and other symptoms caused by PID should seek care immediately. The longer a woman delays treatment, the more likely she is to suffer infertility or an ectopic pregnancy in the future.

The main cause of PID is an untreated STD. Women can protect themselves from PID by taking action to prevent STDs or by getting early treatment if they do get an STD.

Allison L. Greenspan

Joel R. Greenspan

(see also: Sexually Transmitted Diseases )

Bibliography

Centers for Disease Control and Prevention (1998). "1998 Guidelines for Treatment of Sexually Transmitted Diseases." Morbidity and Mortality Weekly Report 47(RR-1):79–86.

Westrom, L., and Eschenbach, D. (1999). "Pelvic Inflammatory Disease." In Sexually Transmitted Diseases, 3rd edition, eds. K. Holmes, P. Mardh, P. Sparling et al. New York: McGraw-Hill.

pelvic inflammatory disease (PID), infection of the female reproductive organs, usually resulting from infection with the bacteria that cause chlamydia or gonorrhea . The infection typically first affects the cervical area, then spreads to the uterus, fallopian tubes, ovaries, and abdomen. Symptoms may be absent but usually include pelvic pain and vaginal discharge. PID can cause abscesses and scarring in the fallopian tubes that can block fertilization or interrupt the egg's progress, resulting in ectopic (tubal) pregnancy and loss of the fetus. Over 1 million women are diagnosed with PID each year in the United States; 100,000 typically become infertile.

pelvic inflammatory disease (PID) n. an acute or chronic condition in which the uterus, Fallopian tubes, and ovaries are inflamed and infected. It is usually the result of chlamydial or gonorrhoeal infection ascending from the vagina and may be associated with lower abdominal pain, irregular vaginal bleeding, and vaginal discharge. Blocking of the Fallopian tubes is a common result; this can lead to ectopic pregnancy or infertility. In the chronic state, when pelvic adhesions have developed, surgical removal of the diseased tissue may be necessary.

Pelvic Inflammatory Disease (PID)

Carrie and Reg’s Story

What Causes PID?

What Does PID Do in the Body?

Who Is at Risk for PID?

What Are the Symptoms of PID?

How Is PID Diagnosed?

How Is PID Treated?

How Can PID Be Prevented?

Resources

Pelvic inflammatory disease is an infection of the female reproductive system, including the cervix*, uterus*, ovaries*, and especially the fallopian tubes*. It usually is caused by a sexually transmitted disease and can reduce a woman’s ability to get pregnant.

KEYWORDS

for searching the Internet and other resources

Ectopic pregnancy

Infertility

Salpingitis

Sexually transmitted disease

* cervix

(SER-viks) is the lower, narrow end of the uterus.

* uterus

(YOO-te-rus) in humans is the organ in females for containing and nourishing the young during development in the period before birth. Also called the womb.

* ovaries

(O-va-reez) are the sexual glands in which eggs (ova) are formed in women.

* fallopian tubes

(fa-LO-pe-an tubes) are two long slender tubes in females that connect the ovaries and the uterus. Typically, a fallopian tube is where conception (kon-SEP-shun) takes place.

Carrie and Reg’s Story

Two years after Carrie and Reg got married, they decided to start a family. Carrie began looking at the ads for strollers and baby clothes. But after a year, she had not gotten pregnant. She was sure she did not have a medical problem. After another 6 months of trying, Carrie and Reg decided to see a doctor who had experience with fertility problems.

The doctor asked if Carrie had ever had pelvic inflammatory disease (PID). She said no, she had not even heard of it. But in a series of tests, her body told a different story. Carrie’s fallopian tubes (the place where egg meets sperm in conception) had been scarred by PID. After laser surgery removed the scar tissue and opened the blocked passageways, Carrie finally got pregnant.

When healthy young women have difficulty getting pregnant, damage from pelvic inflammatory disease is one of the many possible causes. In most cases, the women do not know they had the disease and never got treated. Quick treatment of PID can reduce the chances that it will cause infertility.

What Causes PID?

Most commonly, women get PID after they have had a sexually transmitted disease (chlamydial [kla-MID-e-al] infection or gonorrhea [gon-o-REE-a]) that was not treated, often because it was not noticed. The bacteria*, named Chlamydia trachomatis and Neisseria gonorrhoeae, then can move up from the vagina* to infect other parts of the reproductive system. PID often involves a wide range of other bacteria as well. In many cases, doctors cannot identify the bacteria involved.

* bacteria

(bak-TEER-ee-a) are round, spiral, or rod-shaped single-celled microorganisms without a distinct nucleus that commonly multiply by cell division. Some types may cause disease in humans, animals, or plants.

* vagina

(va-JY-na) In girls and women, the vagina is the canal that leads from the uterus—the womb (the organ where a baby develops)—to the outside of the body.

PID also can develop after a woman gives birth or has an abortion in unsanitary conditions. In rare cases, certain medical procedures done on reproductive organs, such as injecting dye for special x-rays, can lead to PID.

What Does PID Do in the Body?

First, a quick review of conception. The ovary releases an egg into one of a woman’s two fallopian tubes, where it meets with the sperm*. The newly formed embryo* travels through the tube to the uterus, an expandable sac where it will grow into a fetus*.

* sperm

are the tiny, tadpole-like cells males produce in their testicles (TES-ti-kulz) that can unite with a female’s egg to result eventually in the birth of a child.

* embryo

(EM-bree-o) is, in humans, the developing organism from the end of the second week after fertilization to the end of the eighth week.

* fetus

(FEE-tus) is, in humans, the unborn offspring in the period after it is an embryo, from 9 weeks after fertilization until birth.

In PID, the bacteria usually infect the cervix and then travel upward and infect the fallopian tubes, a condition called salpingitis (sal-pin-JY-tis). Doctors sometimes use that name as a synonym for PID. But PID also can involve the uterus and the ovaries. In severe cases, a collection of pus can form in the ovaries and fallopian tubes, called a tubo-ovarian abscess, or the infection can spread to the membrane* around the reproductive organs, a condition called pelvic peritonitis (per-i-to-NY-tis).

* membrane

(MEM-brayn) is a thin layer of tissue that covers a surface, lines a cavity, or divides a space or organ.

The body usually fights off the infection. But in the struggle, tissue can be damaged and scarred, causing blockages in the delicate fallopian tubes. That means the egg and sperm may not be able to meet, or, if they do, the fertilized egg or embryo may not be able to reach the uterus.

Of women who have PID one time, about 10 percent become infertile. After three bouts of the disease, more than half may be infertile. Prompt treatment, within 3 days of symptoms, can help prevent problems.

Women who have had PID also are more likely than other women to have an ectopic (ek-TOP-ik) pregnancy. That means the embryo starts growing outside the uterus, usually in the fallopian tubes. Such a pregnancy cannot produce a baby and, if it is not ended, poses a very serious risk to the woman’s safety because the growing embryo will rupture the fallopian tubes and cause life-threatening hemorrhage*.

* hemorrhage

(HEM-or-ij) means heavy and uncontrolled bleeding, often in the internal organs.

Who Is at Risk for PID?

PID affects only women and is rare unless a woman is sexually active. Sexually active teenagers are at the highest risk by far, followed by women in their early twenties. The risk increases if a woman has many sexual partners, has sexual intercourse very frequently even with a single partner, or uses an IUD (intrauterine [in-tra-YOO-ter-in] device), a birth-control device inserted in the uterus. Frequent douching (inserting fluid into the vagina to “clean” it) may also increase the risk of PID.

What Are the Symptoms of PID?

It has been estimated that 60 percent of all cases of PID have symptoms so mild they go unnoticed. Noticeable symptoms often include:

• Pain in the lower abdomen* or pelvis
• Very sharp pain when the doctor performs a pelvic examination
• A fever of over 100 degrees Fahrenheit (38 degrees Celsius)
• A discharge of pus or irregular bleeding from the vagina
• Pain during urination or intercourse

* abdomen

(AB-do-men), commonly called the belly, is the portion of the body between the chest or thorax (THOR-aks) and the pelvis.

Sometimes, long after an untreated PID infection occurs, women have chronic* (persistent) pain in the pelvis. This is sometimes called chronic PID.

* chronic

(KRON-ik) means continuing for a long period of time.

How Is PID Diagnosed?

PID can be difficult to diagnose. Many conditions have similar symptoms, and no simple test can tell for sure if a woman has PID. Because it is so important to treat PID quickly, doctors usually start treatment if the symptoms even suggest PID.

To try to confirm the diagnosis, doctors do blood tests to look for general evidence of infection. They test for chlamydial infection and gonorrhea, and they do a pregnancy test to determine whether the symptoms are being caused by an ectopic pregnancy.

Ultrasound, a painless procedure that uses sound waves to create an image of the organs, can help doctors look for a tubo-ovarian abscess.

The most definitive test for PID is laparoscopy (la-pa-ROS-ko-pee), a surgical procedure in which a narrow device is inserted through a small incision into the abdomen so the doctor can look inside the belly. Laparoscopy usually is done only if treatment is not working or if the doctor suspects the woman may have another condition, such as appendicitis (a-pen-di-SY-tis), that requires emergency surgery.

How Is PID Treated?

Combinations of antibiotics (an-ty-by-OT-iks) that fight a wide range of bacteria are given for at least 2 weeks, usually in pills to be taken at home. If a woman is pregnant or particularly ill, she usually is hospitalized for at least a few days and given antibiotics intravenously*.

* intravenously

(in-tra-VEE-nus-lee) means injected directly into the veins.

If a woman has an abscess, it may need to be drained through a tube or catheter (CATH-e-ter) inserted into the abdomen. If an abscess ruptures, or breaks open, immediate surgery is necessary.

If a woman has PID, any man who had sex with her in the previous 2 months should be treated for possible chlamydial infection and gonorrhea. Even if he has no symptoms, chances are high that he is infected and could reinfect the woman or other partners.

How Can PID Be Prevented?

Like chlamydial infections and gonorrhea, PID most surely is prevented by not having sex. A sexually active woman is most protected if she has sex only with one faithful partner, that is, a partner who has sex only with her. Short of that, a woman should limit her sexual partners. Latex condoms worn by the man during sexual activity can prevent PID if they are used correctly at all times.

A woman should seek immediate treatment if she suspects that she, or a sexual partner, has a sexually transmitted disease. Because these diseases often cause no symptoms, health officials recommend that all sexually active young women, especially teenagers, get tested routinely for chlamydial infections and gonorrhea. When chlamydial infection screening of young women was tried as an experiment, it reduced the number of cases of PID.

The U.S. and the World

• In the United States, it is estimated that more than 750,000 women get PID each year. Most U.S. cases are caused by a sexually transmitted disease.
• With its complications of infertility and ectopic pregnancy, PID is estimated to cost the U.S. economy $4 billion a year.
• In developing nations of Africa and Asia, PID is far more common, with many infections caused by childbirth or abortions occurring in unsanitary settings.

See also

Bacterial Infections

Chlamydial Infections

Gonorrhea

Infection

Peritonitis

Sexually Transmitted Diseases

Resources

Book

Brodman, Michael, John Thacker, and Rachel Kranz. Straight Talk about Sexually Transmitted Diseases. New York: Facts on File, 1994. Focuses on prevention for young people.

Organization

U.S. Centers for Disease Control and Prevention (CDC), 1600 Clifton Road N.E., Atlanta, GA 30333. The CDC sponsors a National Sexually Transmitted Diseases Hotline. Telephone 800-227-8922