Pelvic Inflammatory Disease (PID)

Pelvic inflammatory disease (PID) refers to infection of the uterus (womb), fallopian tubes (tubes that carry eggs from the ovaries to the uterus) and other reproductive organs that causes symptoms such as lower abdominal pain. It is a serious complication of some sexually transmitted diseases (STDs), especially chlamydia and gonorrhea. PID can damage the fallopian tubes and tissues in and near the uterus and ovaries. PID can lead to serious consequences including infertility, ectopic pregnancy (a pregnancy in the fallopian tube or elsewhere outside of the womb), abscess formation, and chronic pelvic pain.

Each year in the United States, it is estimated that more than 750,000 women experience an episode of acute PID. As many as 15 percent of these women may become infertile as a result of PID. A large proportion of the ectopic pregnancies occurring every year are due to the consequences of PID.

PID occurs when bacteria move upward from a woman's vagina or cervix (opening to the uterus) into her reproductive organs. Many different organisms can cause PID, but many cases are associated with gonorrhea and chlamydia, two very common bacterial STDs. A prior episode of PID increases the risk of another episode because the reproductive organs may be damaged during the initial bout of infection.

Sexually active women in their childbearing years are most at risk, and those younger than age 25 are more likely to develop PID than those older than 25. This is partly because the cervix of teenage girls and young women is not fully matured, increasing their susceptibility to the STDs that are linked to PID.
The more sex partners a woman has, the greater her risk of developing PID. Also, a woman whose partner has more than one sex partner is at greater risk of developing PID, because of the potential for more exposure to infectious agents.

Women who douche may have a higher risk of developing PID compared with women who do not douche. Research has shown that douching changes the vaginal flora (organisms that live in the vagina) in harmful ways, and can force bacteria into the upper reproductive organs from the vagina.

Women who have an intrauterine device (IUD) inserted may have a slightly increased risk of PID near the time of insertion compared with women using other contraceptives or no contraceptive at all. However, this risk is greatly reduced if a woman is tested and, if necessary, treated for STDs before an IUD is inserted.

• Using an IUD (intrauterine device)
• Bacteria (germs)
• Douching. Women who douche once or twice a month are more likely to have PID than those who douche less than once a month. Douching may ease symptoms of an infection, thus delaying effective treatment.

• Dull pain or tenderness in the lower abdomen
• Nausea and vomiting
• Bleeding between menstrual periods
• Increased or changed vaginal discharge
• Pain during sex
• Fever and chills
• It is possible for a woman to have PID and be asymptomatic (without symptoms), or symptoms too mild to notice, for an unknown period of time.
• PID can be misdiagnosed as appendicitis, ectopic pregnancy, ruptured ovarian cysts or other problems.

Prompt and appropriate treatment can help prevent complications of PID, including permanent damage to the female reproductive organs. Infection-causing bacteria can silently invade the fallopian tubes, causing normal tissue to turn into scar tissue. This scar tissue blocks or interrupts the normal movement of eggs into the uterus. If the fallopian tubes are totally blocked by scar tissue, sperm cannot fertilize an egg, and the woman becomes infertile. Infertility also can occur if the fallopian tubes are partially blocked or even slightly damaged. As many as 15 percent of women with PID may become infertile, and if a woman has multiple episodes of PID, her chances of becoming infertile increase.

In addition, a partially blocked or slightly damaged fallopian tube may cause a fertilized egg to remain in the fallopian tube. If this fertilized egg begins to grow in the tube as if it were in the uterus, it is called an ectopic pregnancy. As it grows, an ectopic pregnancy can rupture the fallopian tube causing severe pain, internal bleeding, and even death.
Scarring in the fallopian tubes and other pelvic structures can cause chronic pelvic pain (pain that lasts for months or even years). Women with repeated episodes of PID are more likely to suffer infertility, ectopic pregnancy, or chronic pelvic pain.

The diagnosis of PID can be made when all three of the following symptoms are found during a pelvic exam:

• Lower abdominal tenderness
• Tenderness of fallopian tubes and ovaries
• Tenderness of the cervix

PID is difficult to diagnose because the symptoms are often subtle and mild. Many episodes of PID go undetected because the woman or her health care provider fails to recognize the implications of mild or nonspecific symptoms. Because there are no precise tests for PID, a diagnosis is usually based on clinical findings. If symptoms such as lower abdominal pain are present, a health care provider should perform a physical examination to determine the nature and location of the pain and to check for fever, abnormal vaginal or cervical discharge, and for evidence of gonorrheal or chlamydial infection. If the findings suggest PID, treatment is necessary.

The health care provider may order tests to identify the infection-causing organism (e.g., chlamydial or gonorrheal infection) or to distinguish between PID and other problems with similar symptoms. A pelvic ultrasound is a helpful procedure for diagnosing PID. An ultrasound can view the pelvic area to see whether the fallopian tubes are enlarged or whether an abscess is present. In some cases, a laparoscopy may be necessary to confirm the diagnosis. A laparoscopy is a surgical procedure in which a thin, rigid tube with a lighted end and camera (laparoscope) is inserted through a small incision in the abdomen. This procedure enables the doctor to view the internal pelvic organs and to take specimens for laboratory studies, if needed.

Treatment may include antibiotics used to treat gonorrhea, chlamydia, streptococci and other gram-negative bacteria.

Aggressive treatment of PID is recommended for women with HIV who may be more likely to require surgical intervention.

PID can be cured with several types of antibiotics. A health care provider will determine and prescribe the best therapy. However, antibiotic treatment does not reverse any damage that has already occurred to the reproductive organs. If a woman has pelvic pain and other symptoms of PID, it is critical that she seek care immediately. Prompt antibiotic treatment can prevent severe damage to reproductive organs. The longer a woman delays treatment for PID, the more likely she is to become infertile or to have a future ectopic pregnancy because of damage to the fallopian tubes.

Because of the difficulty in identifying organisms infecting the internal reproductive organs and because more than one organism may be responsible for an episode of PID, PID is usually treated with at least two antibiotics that are effective against a wide range of infectious agents. These antibiotics can be given by mouth or by injection. The symptoms may go away before the infection is cured. Even if symptoms go away, the woman should finish taking all of the prescribed medicine. This will help prevent the infection from returning. Women being treated for PID should be re-evaluated by their health care provider three days after starting treatment to be sure the antibiotics are working to cure the infection. In addition, a woman’s sex partner(s) should be treated to decrease the risk of re-infection, even if the partner(s) has no symptoms. Although sex partners may have no symptoms, they may still be infected with the organisms that can cause PID.

Hospitalization to treat PID may be recommended if the woman (1) is severely ill (e.g., nausea, vomiting, and high fever); (2) is pregnant; (3) does not respond to or cannot take oral medication and needs intravenous antibiotics; (4) has an abscess in the fallopian tube or ovary (tubo-ovarian abscess); or (5) needs to be monitored to be sure that her symptoms are not due to another condition that would require emergency surgery (e.g., appendicitis). If symptoms continue or if an abscess does not go away, surgery may be needed. Complications of PID, such as chronic pelvic pain and scarring are difficult to treat, but sometimes they improve with surgery.

• Take all medications as directed.
• Set up a follow-up exam 48 to 72 hours after start of treatment to make sure the medicine is working.
• Return for another exam after completion of treatment to make sure the infection is completely gone.
• Tell your partner to get tested and treated.
• Do not have sex until you and your partner(s) have been treated and cured.

However, antibiotic treatment does not reverse any damage that has already occurred to the reproductive organs.

Women can protect themselves from PID by taking action to prevent STDs or by getting early treatment if they do get an STD.

The surest way to avoid transmission of STDs is to abstain from sexual intercourse, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Latex male condoms, when used consistently and correctly, can reduce the risk of transmission of chlamydia and gonorrhea.

CDC recommends yearly chlamydia testing of all sexually active women age 25 or younger, older women with risk factors for chlamydial infections (those who have a new sex partner or multiple sex partners), and all pregnant women. An appropriate sexual risk assessment by a health care provider should always be conducted and may indicate more frequent screening for some women.

Any genital symptoms such as an unusual sore, discharge with odor, burning during urination, or bleeding between menstrual cycles could mean an STD infection. If a woman has any of these symptoms, she should stop having sex and consult a health care provider immediately. Treating STDs early can prevent PID. Women who are told they have an STD and are treated for it should notify all of their recent sex partners so they can see a health care provider and be evaluated for STDs. Sexual activity should not resume until all sex partners have been examined and, if necessary, treated.

Untreated PID infections may lead to:

• Infertility. As many as 10 percent of women with PID will not be able to have children as a result of scarring or damage to cells lining the fallopian tubes.
• Cystitis (inflammation of the urinary bladder)
• Ectopic (tubal) pregnancy (a pregnancy in the fallopian tube or elsewhere outside the womb)
• Recurrent episodes of PID
• Chronic pelvic pain

Hospitalization to treat PID may be recommended if the woman (1) is severely ill, e.g., nausea, vomiting, and high fever); (2) pregnant; (3) does not respond to or cannot take oral medications and needs intravenous antibiotics; (4) or has an abscess in the fallopian tube or ovary. If symptoms continue or if an abscess does not go away, surgery may be needed.

Yes. Telling a partner can be hard, but keep in mind that most people with an STD don't know they have it. It's important that you talk to your partner as soon as possible so she or he can get treatment. Men are more likely than women to have symptoms of chlamydia or gonorrhea (two STDs that cause PID). It is possible to pass STDs back and forth, so if you get treated and your partner does not, you may get infected again.

Yes. Because STDs which can cause PID often do not have symptoms, you may need to talk to your doctor or nurse about whether or not you should be tested. If you are having unprotected sex or discover that your partner is having unprotected sex with another person, you may want to ask your doctor or nurse about being tested.

• Illinois Department of Public Health
  IDPH HIV/STD Hotline 800-243-2437 (TTY 800-782-0423)
• U.S. Centers for Disease Control and Prevention (CDC) 
  www.cdc.gov/std/ 
  CDC-INFO Hotline (7am-7pm Mon.-Fri. Closed Holidays)
  STD information and referrals to STD Clinics 
  800-CDC-INFO (800-232-4636) 
  TTY: 888-232-6348 
  In English, en Español
• CDC National Prevention Information Network (NPIN) 
  P.O. Box 6003 
  Rockville, MD 20849-6003 
  800-458-5231 
  888-282-7681 Fax 
  E-mail: info@cdcnpin.org
• American Social Health Association (ASHA) 
  P. O. Box 13827 
  Research Triangle Park, NC 27709-3827 
  919-361-8400