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
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 years 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
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.
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.
trachomatis and other bacteria may behave in a similar manner.
Researchers do not know how other bacteria that normally inhabit the
vagina 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.
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 through it can seriously damage the reproductive organs.
Risk Factors for
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
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 may also ease
discharge caused by an infection, so the woman delays seeking health
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 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.
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 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
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 mediation and needs intravenous antibiotics; if she is pregnant
or is an adolescent; if the diagnosis is uncertain and may include
abdominal emergency such as appendicitis; or if she is infected with
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 re-infection, 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 percent of women who have 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
A woman who has had
PID has a 6-to-10 fold 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
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.
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 or re-infection, the risk of infertility is
Note: All information
is based upon materials published by the National Institute of
Allergy and Infectious Diseases (NIAD).
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