Hysteroscopy

Pelvic Inflammatory Disease

Pelvic Inflammatory Disease, or PID, is an infectious disease that affects millions of U.S. women and girls each year. Although usually surprisingly easy to treat, it can be hard to diagnose, and can lead to many long-term and troublesome complications. And, while PID is often a sexually transmitted disease (STD), in many cases it is caused by bacteria that are not necessarily associated with sexual activity. Therefore, all women should understand the signs and symptoms of this illness, the diagnostic and treatment options available, the long-term effects of PID, and methods
of prevention.

Simply put, PID is a specific set of symptoms caused by an infection of the upper parts of the female genital organs (uterus, tubes, or ovaries). One or more bacteria travels from the vagina into and through the cervix (the opening of the uterus located at the very top of the vagina) then into the uterus. The infection may "set up shop" in the uterus, or, more likely, continue up into the fallopian tubes through the tiny openings at the top of the uterus that lead to the tubes. The tubes are extremely fragile and are easily damaged by bacterial infection. If the infection ends at the tubes, we call this "salpingitis" which is another common term for PID. If the infection spreads through the tubes and into the abdominal cavity, it is often called
peritonitis. Generally, the bacteria that cause PID can infect and inflame any or all of the organs they encounter although in most cases the fragile tubes bear the brunt of the infection and are the organs most commonly damaged.

PID can come from any of a number of common bacteria. The sexually transmitted organisms chlamydia and gonorrhea are the most common "bugs" found in the tubes of women affected with PID. However, PID is not necessarily a venereal disease, as other, non-sexual bacteria, have been isolated in the tubes of women with this disease. For example, in unusual cases surgical procedures involving the uterus can lead to PID from the normal bacteria found in every woman's vagina. In other cases chlamydia, gonorrhea, and the bacteria found normally in the vagina may work hand-in-hand to cause the infection. Since we can only determine the exact bacteria by culturing the fallopian tubes, a difficult and complicated process, we treat PID by giving antibiotics that will kill all the possible bacteria that can cause the illness.

Certain activities place one at increased risk for PID. The most important is
unprotected sexual activity. It is simply impossible to tell if a sexual partner has chlamydia or gonorrhea, and every health care provider that cares for women has heard a patient with newly-diagnosed PID lament that "he seemed like such a nice guy." Having multiple partners, early loss of virginity, or dating and sleeping with multiple partners at one time are all risk factors for PID (and other diseases, such as hepatitis, syphilis, herpes, HIV, genital warts, and abnormal Pap smears and cervical cancer). Other risk factors include having a surgical procedure that involves penetration of the cervix, such as a D & C, endometrial biopsy, or IUD insertion). To protect you from PID your health care provider will use sterile technique when
performing the above procedures. To protect yourself from PID you should strongly consider the use of latex condoms during sexual activity, especially when in a non-monogamous relationship! Furthermore, one should strongly consider being involved in a monogamous relationship, rather than being sexually active with more than one person.

There are many signs and symptoms of PID. More common ones include lower pelvic pain. In acute PID most patients report rapidly worsening abdominal pain, perhaps similar to appendicitis, that develops over a few days and often leads to a visit to the emergency room or your doctor's office. Chronic pelvic pain, which occurs over many months, may also be due to "chronic" PID. Other symptoms of acute PID may include fever, a vaginal discharge, pain with walking (sometimes called the "PID shuffle"), or irregular vaginal bleeding. In severe cases the patient may report nausea/ vomiting and dehydration. Obviously these symptoms need evaluation as soon as possible by a health care provider.

Your doctor or the emergency room doctor will want to perform a careful
examination of your abdomen and genital organs. This will usually involve looking inside the vagina with a speculum to take cultures of the cervix, and a bimanual exam involving one or two fingers in the vagina while feeling for tenderness around the ovaries. In many cases you will have blood drawn for a pregnancy test, a blood count, and perhaps blood cultures. Other tests may include cervical cultures and perhaps an ultrasound of the ovaries (if your ovaries are too painful to adequately examine with the bimanual exam) and evaluation for other sexually-transmitted infections (i.e. HIV, hepatitis, herpes, syphilis).

Treatment for PID is either outpatient, which usually consists of an antibiotic shot or pills, or inpatient, which consists of intravenous antibiotics, depending on the severity of the symptoms. In some cases the diagnosis may be in doubt, and since conditions like appendicitis can mimic PID, your doctor may want you to undergo repeated exams or even a laparoscopy to pin down the diagnosis. If an abscess develops around the ovaries, you will need prolonged hospitalization for up to a week . Please
remember to take all of the antibiotic pills that are prescribed to you, to prevent a recurrence. Furthermore, if your doctor suspects your case of PID is caused by a sexually-transmitted organism, your partner will need treatment to prevent further spread of this infection.

There are many unfortunate long-term complications that can develop from PID, including infertility (an emotionally and financially devastating complication), chronic pelvic pain, scar tissue (called adhesions), and an increase in tubal ectopic pregnancies. These develop in at least 1/4 of patients who have PID. Of course, having PID increases the chance of spreading this to sexual partners, which makes this a public health issue. Furthermore, some of the bacteria causing PID can cause complications to an unborn baby if not treated during pregnancy. PID itself is rare
during pregnancy, but the two most common bacteria that cause PID, gonorrhea and chlamydia, both can cause problems if untreated during pregnancy. Each of these complications discussed can produce severe symptoms and lead to numerous visits to the doctor and billions spent in annual health care costs. 1/4 of PID cases occur in teenage girls. Teenagers rarely consider the long-term consequences of their behavior, but they should. There are many women facing expensive and perhaps
painful infertility treatments that wish they had been more careful about sexual activity when they were younger. This is one of many reasons that parents must sit down with their pre-teen children and discuss sexuality issues. Sexual activity in teenagers is no longer just an issue of morals and family values. Probably all teenagers consider becoming sexually active, and while many do not, research has repeatedly shown that the majority of young women are experimenting sexually. Thus, teenage sexuality, a potentially life-threatening or life-altering activity, simply must be
addressed before children reach an age where they start thinking about sexual activity. Contact your health care provider, or look for one of many books available on this subject at your local library or bookstore. If you are simply too uncomfortable discussing these issues with your child, please make an appointment with your doctor so that he or she can sit down with your child and have a confidential talk about human sexuality. You may be asked to leave during this discussion, which I feel is appropriate, since you will certainly want your son or daughter to feel comfortable talking about these issues with a health care provider.

In summary, PID is a common but treatable infection that can usually be prevented by safe-sex practices. In cases where the infection is due to a medical procedure, rapid treatment will usually prevent long-term complications. Women who have had multiple sexual partners or who are in a non-monogamous relationship should consider visiting their health care provider for an evaluation and perhaps treatment.

D. Ashley Hill, M.D.
Associate Director
Department of Obstetrics and Gynecology
Florida Hospital Family Practice Residency
Orlando, Florida
407-897-1668