Pelvic Inflammatory Disease

Pelvic Inflammatory Disease

What It Is--And Isn't

For a long time Sarah didn't know she had pelvic inflammatory disease (PID). She had suffered bouts of pelvic pain and fever, but she lacked some classic signs of the disease, so doctors didn't detect it right away.

More than three years later, they did.

Sarah had PID caused by sexually transmitted diseases (STDs) that had gone undiscovered. She was married and doctors didn't think STDs could be an issue. But two infections, mycoplasma and chlamydia, had been bouncing back and forth between Sarah and her husband for who knows how long. In Sarah, the STDs invaded her upper reproductive tract, causing PID.

The disease had moved into her fallopian tubes, causing tremendous pain. Doctors wanted to perform a hysterectomy, but Sarah hadn't had children yet, and she was determined to find someone to help her. Eventually she found a doctor in New York who could. With surgery and antibiotics, he treated her successfully, and she went on to have two healthy children.

Sarah is one of the lucky ones. Others aren't so fortunate. In many cases, PID goes undetected for so long that it robs women of their fertility and reproductive health.

Understanding PID

PID is an upper genital tract infection that's diagnosed in an estimated one million American women every year. The disease often (but not always) develops when an STD in a woman's lower genital tract goes unchecked. The infection moves into the upper genital tract and PID develops. The disease can cause discomfort and pain--or show no signs at all, making it difficult for doctors to diagnose. One in four women who get PID experiences complications, including ectopic (tubal) pregnancy, infertility, recurrent pain and recurrent PID. Infertility occurs in 12 percent of women with PID after they've had it once, 25 percent after two occurrences and 50 percent after three or more episodes.

There are several theories on how organisms move up from the vagina into the uterus. Some experts say it is possible that organisms initially attach to the cervix. Then, during menstruation, hormonal and cervical changes occur that make it easier for the organisms to pass through the cervical opening into the uterus: A mucus plug that seals off the uterus during the other phases of the cycle is expelled at menstruation, and the cervix is open for organisms to pass through. Others believe that the organisms attach to sperm and essentially hitch a ride up.

The uterus is normally a sterile environment, so when bacteria or sexually transmitted organisms that don't belong there enter, trouble may develop. The organisms can penetrate the endometrium, or lining of the uterus, causing an inflammatory condition known as endometritis, which may be painful. They can also attack the fallopian tube, infecting and damaging its lining. This inflammation, called salpingitis, is painful and can hamper a woman's ability to become pregnant.

Infections in these areas, as well as the ovaries and lining of the pelvic area, make up PID.

Who's at Risk

Because PID is usually caused by STDs, having multiple partners and having unprotected sex are the major risk factors, says Joseph Apuzzio, M.D., professor of obstetrics and gynecology and director of the Division of Prenatal Diagnosis and Infectious Diseases at the New Jersey School of Medicine in Newark. But other factors may play a role, too.

Frequent douching may put women at increased risk for PID. One study showed that the risk for women who douched was twice that of women who never douched, and the risk of PID increased as frequency of douching increased.

Smoking may even play a role in PID. One study showed that women who smoked were at greater risk for PID than those who never smoked, and women who smoked ten or more cigarettes per day were at greater risk than those who smoked less.

The intrauterine device (IUD) has also been implicated in placing women at increased risk for PID. Researchers say women are most at risk during the first four months after they've had an IUD inserted. "The initial risk is really from the insertion," says Dr. Apuzzio. If certain bacteria normally present in a woman's vagina get onto the IUD during insertion and get up into the uterus, they can cause infection of the uterus and fallopian tubes, he says. So after an IUD is inserted, women need to tell their doctors of any discomfort, discharge or pain.

Whether oral contraceptives increase the risk for PID is unclear. The consensus among researchers is that oral contraceptives increase the risk of contracting chlamydia if you are exposed to it, says Nancy S. Padian, Ph.D., associate adjunct professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of San Francisco, San Francisco General Hospital. But some researchers believe that being on the Pill will lower the chance that chlamydia will develop into PID, she says. "Somehow, even though it may increase your susceptibility to lower genital tract infections, it may decrease the likelihood that it ascends," says Dr. Padian, who adds that it is not known why.

The STD Connection

The two most common STDs responsible for PID are gonorrhea and chlamydia. Between 20 and 40 percent of women with a history of PID have shown evidence of a chlamydia infection. Chlamydia can cause silent PID--that is, there are no signs of the disease.

Gonorrhea organisms have been found in the cervixes of up to 80 percent of women with PID and in the fallopian tubes of 13 to 18 percent of women with the disease. Women whose PID is caused by gonorrhea generally have noticeable symptoms, including abdominal pain, fever, fatigue, painful intercourse and pain during pelvic exams.

Bacterial vaginosis, a vaginal infection characterized by an overgrowth of harmful bacteria in the vagina, is also believed to be a risk factor for PID. Researchers don't know why, but in some cases the bacteria overgrowth ascends into the upper genital tract, causing PID.

When discovered early, STDs can be treated with antibiotics. But if undetected and left untreated long enough, infection in the uterine lining can leave behind scar tissue that can block the fallopian tube partially or completely and threaten fertility, says Dr. Apuzzio.

Preventive Measures

The first step in preventing PID is to prevent STDs. If you already have one, the next step is to prevent a lower genital tract infection from spreading to your upper genital tract. Here are some tips.

Use condoms. When used properly, condoms are effective protection against STDs. Laboratory studies show that latex condoms are impermeable to just about all STDs.

"If you really want to talk about prevention, it's the same message as it is for HIV, and that's to use condoms," says Dr. Padian. "There isn't any question about that." Latex condoms offer more protection than the more porous lambskin ones, says Dr. Apuzzio. Condoms with the spermicide nonoxynol-9, which has been shown to be effective in killing many infectious organisms, are particularly helpful in preventing some STDs.

"Even in some of our patients who want to use oral contraceptives, we still recommend that they use condoms for the prevention of sexually transmitted disease and some of the organisms that would cause pelvic inflammatory disease," says Dr. Apuzzio.

Or put up other barriers. If your partner won't wear a condom, use a barrier method such as a diaphragm. "Using a barrier is certainly better than nothing. But first choice would be getting your partner to use a condom," says Dr. Padian.

Know your partner. Find out your partner's sexual history before you sleep together. Has he had multiple partners? Does he use condoms? Has he ever had an STD? Was he treated? Has he ever been tested for STDs? "The best thing is to try to eliminate the risk factors, and the risk factors would be having [other] sexual partners or having a partner who has a sexually transmitted disease--gonorrhea or chlamydia. Often individuals don't know they have it and pass it on," says Dr. Apuzzio.

Ask him to get tested. If your partner hasn't been tested for gonorrhea or chlamydia, ask him to have a test. He could have the infection, not know it, and pass it on to you. And then you may not even know it, says Dr. Padian.

Consider regular testing. Dr. Apuzzio says he provides STD testing for women who come to him for their yearly exams.

Know your body. Realize what is normal for you; if you notice any changes, see your doctor. "If you think you have any kind of symptoms, any kind of discharge, dripping, irritation or whatever, get in and see your physician," says Dr. Padian. Pay particular attention when these signs appear right after your period. Women often have their first signs of PID at this time, says Dr. Padian.

"It's really pretty common to have your first symptoms of upper genital tract infection at the time of menstruation--not because you've acquired the infection then but because that's when the infection has had an opportunity to ascend into the upper genital tract," says Dr. Padian.

Get treatment. If you think you may have an infection, see your doctor. Treatment for PID can vary, depending on the severity of your symptoms or the extent of the disease. Your doctor will prescribe antibiotics, which will be given intravenously in the hospital or orally at home.

"This is an infection where we really want to start with the so-called big guns right from the beginning," says Dr. Apuzzio. Treating the disease early and aggressively will decrease the pain and discomfort as well as preserve fertility, he says.

Follow your doctor's directions. Delaying or failing to complete treatment only gives the infection time to spread and cause more damage.

Don't douche. "I don't know that women need to douche unless they are directed to do so by a health professional," says Dr. Apuzzio.