Other than AIDS, pelvic inflammatory disease (PID) is the most common and serious complication of sexually-transmitted diseases (STDs) among women. It is an infection of the upper genital tract and 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.
In 1998, over 1 million women each year were experiencing 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.
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.
It is not clear how these bacteria (e.g. organisms such as Gardnerella vaginalis and Bacteroides) gain entrance into the upper genital tract. The cervical mucous 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, 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.
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.
There is evidence that women who douche once or twice a month may be more likely to acquire 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.
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.
It is important to recognize and deal with signs of discharge with odor or bleeding between cycles, as these could mean infection. Early treatment may prevent the development of PID.
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.
The doctor may also order other tests such as a sonogram, endometrial biopsy, or laparoscopy to distinguish between PID and other serious problems that may mimic PID.
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 25% 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.
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.
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% 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 woman who has had PID has a six- to ten-fold increased risk of tubal pregnancy. In addition, untreated PID can cause chronic pelvic pain and scarring in about 20% of patients. These conditions are difficult to treat but are sometimes improved with surgery.
Another possible complication of PID is the risk of recurrences. 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.
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