Pelvic inflammatory disease (PID) is a general term that refers to infection of the uterus (womb), fallopian tubes (tubes that carry eggs from the ovaries to the uterus) and other reproductive organs. It is a common and serious complication of some sexually transmitted diseases (STDs), especially chlamydia and gonorrhea. PID can damage the fallopian tubes and tissues in and near the uterus and ovaries. Untreated PID can lead to serious consequences including infertility, ectopic pregnancy (a pregnancy in the fallopian tube or elsewhere outside of the womb), abscess formation, and chronic pelvic pain.
Each year in the United States, it is estimated that more than 1 million 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 the ectopic pregnancies occurring every year are due to the consequences of PID. Annually more than 150 women die from PID or its complications.
PID occurs when bacteria move upward from a woman's vagina or cervix (opening to the uterus) into her reproductive organs. Many different organisms can cause PID, but many cases are associated with gonorrhea and chlamydia, two very common bacterial STDs. A prior episode of PID increases the risk of another episode because the reproductive organs may be damaged during the initial bout of infection.
Sexually active
women in their childbearing years are most at risk, and those under
age 25 are more likely to develop PID than those older than 25.
This is because the cervix of teenage girls and young women is
not fully matured, increasing their susceptibilty to the STDs that
are linked to PID.
The more sex partners
a woman has, the greater her risk of developing PID. Also, a woman
whose partner has more than one sex partner is at greater risk
of developing PID, because of the potential for more exposure to
infectious agents.
Women who douche
may have a higher risk of developing PID compared with women who
do not douche. Research has shown that
douching changes the vaginal flora (organisms that live in the
vagina) in harmful ways, and can force bacteria into the upper
reproductive organs from the vagina.
Women who have an
intrauterine device (IUD) inserted may have a slightly increased
risk of PID near the time of insertion compared with women using
other contraceptives or no contraceptive at all. However, this
risk is greatly reduced if a woman is tested and, if necessary,
treated for STDs before an IUD is inserted.
Symptoms of PID vary from none to severe. When PID is caused by chlamydial infection, a woman may experience mild symptoms or no symptoms at all, while serious damage is being done to her reproductive organs. Because of vague symptoms, PID goes unrecognized by women and their health care providers about two thirds of the time. Women who have symptoms of PID most commonly have lower abdominal pain. Other signs and symptoms include fever, unusual vaginal discharge that may have a foul odor, painful intercourse, painful urination, irregular menstrual bleeding, and pain in the right upper abdomen (rare).
Prompt and appropriate treatment can help prevent complications of PID. Without treatment, 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 the fallopian tubes are totally blocked by scar tissue, sperm cannot fertilize an egg, and the woman becomes infertile. Infertility also can occur if the fallopian tubes are partially blocked or even slightly damaged. About one in eight women with PID becomes infertile, and if a woman has multiple episodes of PID, her chances of becoming infertile increase.
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 pregnancy. As it grows, an ectopic pregnancy
can rupture the fallopian tube causing severe pain, internal bleeding,
and even death.
Scarring in the
fallopian tubes and other pelvic structures can also cause chronic
pelvic pain (pain that lasts
for months or even years). Women with repeated episodes of PID
are more likely to suffer infertility, ectopic pregnancy, or
chronic pelvic pain.
PID is difficult to diagnose because the symptoms are often subtle and mild. Many episodes of PID go undetected because the woman or her health care provider fails to recognize the implications of mild or nonspecific symptoms. Because there are no precise tests for PID, a diagnosis is usually based on clinical findings. If symptoms such as lower abdominal pain are present, a health care provider should perform a physical examination to determine the nature and location of the pain and check for fever, abnormal vaginal or cervical discharge, and for evidence of gonorrheal or chlamydial infection. If the findings suggest PID, treatment is necessary.
The health care
provider may also order tests to identify the infection-causing
organism (e.g., chlamydial or gonorrheal infection) or to distinguish
between PID and other problems with similar symptoms. A pelvic
ultrasound is a helpful procedure for diagnosing PID. An ultrasound
can view the pelvic area to see whether the fallopian tubes are
enlarged or whether an abscess is present. In some cases, a laparoscopy
may be necessary to confirm the diagnosis. A laparoscopy is a minor
surgical procedure in which a thin, flexible tube with a lighted
end (laparoscope) is inserted through a small incision in the lower
abdomen. This procedure enables the doctor to view the internal
pelvic organs and to take specimens for laboratory studies, if
needed.
PID can be cured with several types of antibiotics. A health care provider will determine and prescribe the best therapy. However, antibiotic treatment does not reverse any damage that has already occurred to the reproductive organs. If a woman has pelvic pain and other symptoms of PID, it is critical that she seek care immediately. Prompt antibiotic treatment can prevent severe damage to reproductive organs. The longer a woman delays treatment for PID, the more likely she is to become infertile or to have a future ectopic pregnancy because of damage to the fallopian tubes.
Because of the difficulty
in identifying organisms infecting the internal reproductive organs
and because more than one organism may be responsible for an episode
of PID, PID is usually treated with at least two antibiotics that
are effective against a wide range of infectious agents. These
antibiotics can be given by mouth or by injection. The symptoms
may go away before the infection is cured. Even if symptoms go
away, the woman should finish taking all of the prescribed medicine.
This will help prevent the infection from returning. Women being
treated for PID should be re-evaluated by their health care provider
two to three days after starting treatment to be sure the antibiotics
are working to cure the infection. In addition, a woman’s sex partner(s) should be treated to decrease the risk of re-infection, even if the partner(s) has no symptoms. Although sex partners may have no symptoms, they may still be infected with the organisms that can cause PID.
Hospitalization
to treat PID may be recommended if the woman (1) is severely ill
(e.g., nausea, vomiting, and high fever); (2) is pregnant; (3)
does not respond to or cannot take oral medication and needs intravenous
antibiotics; or (4) has an abscess in the fallopian tube or ovary
(tubo-ovarian abscess). If symptoms continue or if an abscess does
not go away, surgery may be needed. Complications of PID, such
as chronic pelvic pain and scarring are difficult to treat, but
sometimes they improve with surgery.
STD (mainly untreated Chlamydia or gonorrhea) is the main preventable cause of PID. Women can protect themselves from PID by taking action to prevent STDs or by getting early treatment if they do get an STD.
The surest way to
avoid transmission of STDs is to abstain from sexual intercourse,
or to be in a long-term mutually monogamous relationship with a partner
who has been tested and is known to be uninfected.
Latex male condoms,
when used consistently and correctly, can reduce the risk of transmission
of chlamydia and gonorrhea.
CDC recommends yearly
chlamydia testing of all sexually active women age 25 or younger
and of older women with risk factors for chlamydial
infections
(those who have a new sex partner or multiple sex partners).
An appropriate sexual risk assessment by a health care provider should
always be
conducted and may indicate more frequent screening for some women.
Any genital symptoms
such as an unusual sore, discharge with odor,
burning during urination, or bleeding between menstrual cycles
could mean an STD infection. If a woman has any of these symptoms,
she
should stop having sex and consult a health care provider immediately.
Treating STDs early can prevent PID. Women who are told they
have an STD and are treated for it should notify all of their recent
sex partners so they can see a health care provider and be evaluated
for STDs. Sexual activity should not resume until all sex partners
have been examined and, if necessary, treated.
Division of STD
Prevention (DSTDP)
Centers for Disease Control and Prevention
www.cdc.gov/std
Personal health
inquiries and information about STDs:
CDC National STD and AIDS Hotlines
(800) 227-8922 or (800) 342-2437
En Espanol (800) 344-7432
TTY for the Deaf and Hard of Hearing (800) 243-7889
Resources:
CDC National
Prevention Information Network (NPIN)
P.O. Box 6003
Rockville, MD 20849-6003
1-800-458-5231
1-888-282-7681 Fax
1-800-243-7012 TTY
E-mail info@cdcnpin.org
www.cdcnpin.org
American Social
Health Association (ASHA)
P. O. Box 13827
Research Triangle Park, NC 27709-3827
1-800-783-9877
www.ashastd.org
STD questions: std-hivnet@ashastd.org
Sources
American College of Obstetricians and Gynecologists (ACOG). Pelvic Inflammatory Disease. ACOG Patient Education Pamphlet, 1999.
Centers
for Disease Control and Prevention. Sexually transmitted diseases
treatment guidelines 2002. MMWR 2002;51(no. RR-6).
Westrom, L and Eschenbach,
D. Chapter 58 In: K. Holmes, P. Mardh, P. Sparling et al (eds). Sexually
Transmitted Diseases, 3rd Edition. New York: McGraw-Hill, 1999, 783-809.
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