What is PID (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.
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nopausis : meno- + Greek pausis, pause;
see pause.]