Pelvic Inflammatory Disease: PID

nsidious and often dangerous, Pelvic Inflammatory Disease (PID) is a major health problem in the United States. More than 1 million women experience an episode of PID every year, which translates into an annual price tag of more than $4 billion. If present trends continue, by the turn of the century PID will cost Americans more than $10 billion annually in lost work time and medical bills.

For every four women who have PID, one will develop complications such as infertility or an ectopic pregnancy in one of the fallopian tubes between the ovaries and uterus—a potentially fatal condition.

Pelvic inflammatory disease is not really a single illness. It's actually an umbrella term for a variety of infections of the inner reproductive organs, including the ovaries, the fallopian tubes, the endometrial lining of the uterus, the uterine wall, the ligaments that support the uterus, and even the lining of the abdomen.

Silence Versus Symptoms

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Unfortunately, PID isn't always accompanied by obvious symptoms such as fever, abdominal pain, or a vaginal discharge. Sometimes the disease is “silent” and has mild symptoms or none at all, especially in women whose PID is caused by a germ called Chlamydia trachomatis, the most common cause of sexually transmitted disease. In women who have been rendered infertile by an infection in their fallopian tubes (the medical term is salpingitis), roughly half don't remember having any symptoms at all!

For those who do have symptoms, the most common is a dull, constant pain in the lower abdomen. This pain may be aggravated by movement or sexual activity. The hallmark of the condition is pain or tenderness as the doctor probes during a physical examination.

Since PID is often associated with a coexisting infection of the cervix, or birth canal, some women may notice a vaginal discharge. In fact, this is often one of the first symptoms of the disease. Only about 1 in 3 women who are diagnosed with PID has a fever. Nausea and vomiting may also signal PID, but they usually occur when the disease has progressed to peritonitis, in which the infection spreads to the lining of the abdomen.

INFECTION LURKS HIDDEN FOR MANY WITH PID

If your doctor suspects the infection may be due to an adnexal abscess—a pus-filled pocket of fluid and bacteria around the ovary or fallopian tube—you may have to undergo an ultrasound examination, in which sound waves beamed into the body are used to build an image of internal organs on a computer screen.

The only completely conclusive way to diagnose PID is a surgical procedure called laparoscopy in which a special kind of viewing instrument called a laparoscope is inserted through a small incision below the navel. This type of surgery usually involves general anesthesia that puts you to sleep, but it can often be performed on an out-patient basis and does not usually require overnight hospitalization. By examining the affected organs with the laparoscope, your doctor can make a definite diagnosis. You'll usually be given antibiotics to protect you from further infection by the operation itself. The procedure generally takes less than 45 minutes and most patients can return home after resting from 2 to 6 hours.

Although laparoscopy is necessary for a definitive diagnosis of dangerous conditions such as adnexal abscess or ectopic pregnancy, most cases of PID do not call for it; and most doctors will start treatment for PID immediately if they even suspect the problem. If you have gonorrhea or chlamydia, delaying even a few days can greatly increase your chances of complications such as ectopic pregnancy or infertility. The risk of taking some unnecessary antibiotics is far less than the risk of letting PID go unchecked.

The Leading Culprits

PID is usually caused by more than one kind of bacteria. The bugs most commonly involved are Neisseria gonorrhoeae and Chlamydia trachomatis, both transmitted by sexual intercourse. However, other kinds of bacteria generally accompany them. The infection usually starts in the vagina, then moves up the reproductive system through the cervix, into the uterus, up the fallopian tubes, and finally into the ovaries.

Generally, gonorrhea-associated infections start quickly with more severe symptoms than the ones caused by chlamydia. When chlamydia is the major culprit, symptoms tend to be milder and fewer, developing slowly over a period of months or years. In either case, abdominal pain frequently begins during or shortly after a menstrual period.

Risk Factors

Because its two most common causes are both sexually transmitted, sexual activity is by the far the greatest single risk factor for PID. Youth also increases the odds; roughly 75 percent of all cases of PID occur in sexually active women under 25 years of age. For reasons not yet understood, younger women are more susceptible to chlamydial and gonorrhea-associated infection than older women are. Also, the disease rarely occurs in nonmenstruating women such as girls who have not yet reached sexual maturity as well as pregnant and postmenopausal women.

Clearly, there is a direct relationship between the number of sexual partners a woman has and the risk of PID—the more partners, the greater the risk. A woman who has only one partner does not have an increased risk. If he has had a vasectomy, the risk of PID is actually lowered.

HARBINGER OF TROUBLE TO COME

If a pelvic infection takes hold in the critical corridor between the ovary and the uterus, the resulting inflammation and swelling (see tube on right) can totally block the passage, while pus building up outside the tube can cement it to other organs and spread the infection elsewhere in the abdomen.

Contraceptive Choices and the Risk of PID

It used to be thought that use of an intrauterine device (IUD) increased the risk of pelvic inflammatory disease. However, having a variety of sexual partners appears to be the real culprit. Women who use an IUD with a single partner are at no increased risk of the disease.

For those with multiple partners, certain other kinds of contraceptive devices—condoms, diaphragms, and spermicides—provide greater protection against the bacteria that cause PID than does an IUD. Barriers such as condoms or diaphragms physically prevent the bacteria from moving up the reproductive tract just as they prevent the passage of sperm. Spermicides used with these barrier methods, especially one called nonoxynol 9, can kill the bacteria that cause PID infections. On the other hand, frequent douching after sex can increase the risk of PID by pushing bacteria further up into the reproductive system.

Oral contraceptives don't block the passage of bacteria, but they do hinder them, lowering the risk of contracting PID and often keeping the infection milder. They accomplish this by increasing the thickness of cervical mucus which makes it more difficult for bacteria to move up the reproductive system. They also decrease menstrual flow, which presumably limits the opportunity for bacteria to grow in the upper reproductive tract.

THE DIRE AFTERMATH OF INFECTION

Compare the normal fallopian tube on the left with the victim of PID on the right. Even after the disease has cleared up, it's impossible for an egg to make its way through the scarred, unnaturally narrow channel the infection leaves behind. If PID effectively closes both fallopian tubes, the result is sterility.

Why Pid Is Dangerous

If PID were merely an annoying infection that could be cleared up by antibiotics with no lingering or long-term effects, it wouldn't deserve a chapter in this book. But PID is much more than an annoyance. If the infection moves up the reproductive tract to the fallopian tubes, it can cause permanent damage to these critical reproductive organs, resulting in infertility.

Gonorrhea causes an inflammation that can permanently scar the delicate fallopian tubes, decreasing their width, and making them unfit to transport eggs to the uterus. While chlamydia produces a milder form of infection than does gonorrhea, it can linger in the tubes for months prompting a violent immune response that can damage the tubes just as thoroughly as a sudden bacterial onslaught. Whether it is due to a direct gonoccocal attack on the tubes or the more insidious chlamydial assault, the end result is the same—infertility.

In addition to destroying reproductive capacity, just one episode of PID can greatly increase your chances of having an ectopic pregnancy in which an egg begins to grow in the fallopian tube rather than in the uterus where it belongs. Ectopic pregnancies can be a life-threatening emergency requiring hospitalization and surgery. Experts estimate that the risk of death due to ectopic pregnancy is 10 times greater than it is in childbirth and 50 times greater than it is in properly performed surgery.

A bout of PID also quadruples your chances of suffering chronic (long-term) pelvic pain. If you develop this problem, surgical exploration is necessary to determine the cause and extent of the disease.

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How PID Is Diagnosed

Since PID can range from the “silent” variety (no symptoms) to a full-blown infection complete with pain, fever, and abnormal blood tests, there is no “standard” diagnostic procedure. If your doctor suspects that you may have PID, he or she must be able to distinguish between the disease and emergency conditions such as an ectopic pregnancy and appendicitis. For every 100 women suspected of having PID, about three or four will actually have an ectopic pregnancy and another three or four will turn out to have appendicitis.

Most women who develop PID have abdominal pain, pelvic tenderness, and some symptoms of a lower genital tract infection such as cervicitis. To help confirm the presence of infection, your doctor will probably do a couple of blood tests. There may also be a test for human chorionic gonadotropin, a hormone that rises during pregnancy and can signal that the pain is due not to PID but to an ectopic pregnancy. You will also probably be checked for gonorrhea and chlamydia. Samples swabbed from your cervix, or birth canal, will be taken with a cotton swab and sent to a lab for examination.

THE WORST THAT CAN HAPPEN

With its exit to the uterus blocked by scarring in the fallopian tube, a fertilized egg may become implanted and develop within the tube instead. Such an ectopic (outside the uterus) pregnancy can be fatal if left uncorrected. Cramps and spotting shortly after the first missed period are the major warning signs. Surgery is invariably needed.

Treatment Options

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Since PID infection is almost always caused by more than one kind of bacteria, your doctor will most likely prescribe a combination of antibiotics. Only one woman in four is hospitalized for PID; so unless your infection is severe enough to need hospitalization, you will not receive intravenous (IV) medication.

The Centers for Disease Control and Prevention recommend the following antibiotic treatments for PID outpatients:

• An injection of cefoxitin (Mefoxin) plus
• Probenecid (Benemid) tablets or
• An injection of ceftriaxone (Rocephin) plus
• Doxycline (Vibramycin or Doryx) orally for 14 days or tetracycline (Achromycin V or Sumycin) orally for 14 days
• or
• Ofloxacin tablets (Floxin) plus
• Clindamycin (Cleocin HCl) orally for 14 days or metronidazole (Flagyl) orally for 14 days

Whichever regimen your doctor chooses, you should be checked two or three days after the antibiotics have been started to ensure that they are working. If the antibiotics don't seem to be working, your doctor may suggest hospitalization. If you are hospitalized, you can receive IV antibiotics that can work more quickly and more powerfully than ones you can take on an out-patient basis.

Since the great majority of PID cases are the result of sexually transmitted disease, it's not enough to be cured yourself. You need to make sure your partner also gets treatment. Otherwise, he'll reinfect you as soon as you resume having sex.

Preventing Recurrence

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As is the case with so many illnesses, “an ounce of prevention is worth a pound of cure,” because once you've had PID, it can recur, especially if you're a younger woman. In fact, roughly one of every four women with PID will suffer future episodes, and women who are hospitalized for PID have an even greater chance of entering the hospital again with PID or some related condition.

Perhaps even more alarming, recent studies suggest that silent or symptomless PID may be even more common than the classic kind in which acute abdominal pain warns you that something is wrong. However, there is also good news of sorts. Experts believe that symptomless PID is sexually transmitted, probably through germs such as chlamydia and others called trichomonas and mycoplasma. This means that you can avoid PID by sticking with a single partner, using protection, or refraining from sex.

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