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PID — Pelvic Inflammatory Disease? Pelvic inflammatory disease (PID) affects thousands of women every year, yet many women have never heard of it. Caused by bacteria in the internal reproductive organs, PID can be treated successfully with antibiotics when dealt with quickly. Without prompt diagnosis and treatment, however, PID can lead to long-term complications, including infertility, chronic pain and recurring PID. Unfortunately, there are often no obvious symptoms and, even when there are, women may be misdiagnosed or their symptoms dismissed as 'normal' period pain. These information pages explains what PID is, what causes it, how to treat it and what you can do to help prevent it. What is PID? | |
Pelvic inflammatory disease (PID) is the term used to describe any infection in a woman’s upper genital tract or reproductive organs. An infection can develop in the fallopian tubes (salpingitis), ovaries (oophoritis), lining of the womb (endometritis), the pelvic tissue surrounding the reproductive organs (peritonitis), or a combination of these. When diagnosed early, PID can be successfully treated with antibiotics and rest. If PID goes untreated, it can lead to serious long-term complications, including chronic pelvic pain, ectopic pregnancy (when an embryo begins to develop in the fallopian tube) or infertility. Unfortunately, many women don’t know they have PID until permanent damage has been done. Symptoms The symptoms of PID vary from woman to woman, and some women have no obvious symptoms at all. When symptoms are present, they may include:
Symptoms may appear suddenly, they may come and go, or they may be constant. Many women first notice symptoms of PID during, or just after, their period. If you are concerned that you may have PID, or if you have more than one of the symptoms listed above, talk to your doctor or go to a GUM (genito-urinary medicine) clinic. See Resources for more information. Causes  PID develops when bacteria (germs) get into a woman’s internal reproductive organs. There are a number of ways this can happen. The internal organs are usually protected by the cervix, which blocks bacteria in the vagina from moving up into the womb. But when the cervix is open (e.g. during menstruation or at ovulation), or if the cervix itself becomes infected, bacteria have a greater chance of getting through and causing infection. Bacteria may also get into the reproductive organs during pelvic surgery or invasive procedures that disrupt the cervix, such as abortion, childbirth or insertion of an IUD (intra-uterine device). Bacteria from severe appendicitis can lead to PID if it spreads to the pelvic tissues, but this is uncommon. Chlamydia and Gonorrhoea PID can be caused by many types of bacteria, but most cases are caused by the bacteria from Chlamydia trachomatis and Neisseria gonorrhoea, two sexually transmitted infections (STIs). Both infect a woman’s cervix and can damage its surface, making it easier for bacteria to get to the internal reproductive organs. Chlamydia — Chlamydia is one of the most common sexually transmitted infections in the world, and in the UK, it is the number one cause of PID. It is estimated that as many as one in ten sexually active women under the age of 25 may be infected with chlamydia, and while it is less common in older age groups, the number of cases in people over 25 is on the rise. Chlamydia can live in the body without causing any symptoms for months or years. Up to 70% of women and 50% of men with chlamydia have no noticeable symptoms, but when symptoms are present, in women they are:
It is estimated that 40% of women who have chlamydia will develop PID. PID caused by chlamydia often produces very mild symptoms, if any at all (called silent or subclinical PID). This does not mean the infection is less serious than other forms of PID, but does mean that the infection may go undetected until permanent damage has been done. Gonorrhoea — Like chlamydia, gonorrhoea is found most commonly among teenagers and those in their 20s, but recent public health figures show an increase in gonorrhoea among 35 to 44 year-olds. Up to 50% of women (and 10% of men) who become infected with gonorrhoea have no symptoms. But when symptoms do occur, in women they are:
Other sources of infection Other bacteria commonly found in the vagina can lead to PID if they get past the cervix and into the internal reproductive organs. This is most likely to happen if your cervix has been damaged, if you have had PID before, or if your cervix is opened during a surgical procedure. Pelvic surgery — Any surgery carries the risk of infection, and pelvic surgery is no exception. Bacteria may be introduced from the outside or may be spread internally from one organ to another.  IUD (intra-uterine device) — When the cervix is opened to insert an IUD, bacteria from the vagina have an opportunity to get into the womb. Studies show that the risk of developing PID is increased for about one month following IUD insertion. Childbirth, miscarriage and abortion — The cervix is dilated (opened) during vaginal childbirth, miscarriage and abortion, and this creates an opportunity for bacteria to make their way into the internal reproductive organs. Before undergoing any procedure that disturbs the cervix, you should be screened for chlamydia, even if you are in a monogamous relationship or think you are unlikely to have chlamydia. Risk factors Sexually active women under the age of 25 have the highest risk of developing PID, with most cases occurring in teenagers. This may be because young women are more likely than older women to have multiple sexual partners and practice unsafe sex – two high risk behaviours for getting PID (see below). Another age-related factor that may influence the development of PID is cervical mucus. Thick cervical mucus can protect the cervix from some forms of bacteria (such as gonorrhoea), but young women in their teens tend to have thin mucus that is less protective. Sexual activity — Having multiple sexual partners is one of the main risk factors for developing PID. The more partners you have penetrative sex with, the more likely you are to be exposed to bacteria that can lead to PID, particularly if you are not using barrier contraception – a condom, femidom, diaphragm or cervical cap with spermicide. The rate of PID is lower among lesbians than heterosexual women, and this is probably related to a lower incidence of the STIs that can lead to PID. Some studies suggest that having sex during your period may increase your chances of developing PID. This is believed to be because the cervix is open during menstruation and the presence of blood may help some bacteria to multiply. IUD — The IUD was once thought to increase a woman’s risk of PID significantly, but recent research suggests it may be the process of inserting the IUD that increases risk, not the IUD itself. Current studies show that risk is increased mainly during the month following insertion, and after that, risk is related more to sexual activity and exposure to STIs than to the use of an IUD. The Pill — There is conflicting information about whether the Pill increases or decreases a woman’s risk of PID. The Pill does not protect against sexually transmitted infections, but it does have a thickening effect on cervical mucus that may prevent some bacteria from getting through the cervix. Other risk factors — Once you’ve had PID, you have an increased risk of getting it again. Smoking, douching and cocaine-use also have been linked to an increased risk of PID, but more research is needed to investigate these links. Prevention The best way to prevent PID is to protect yourself from sexually transmitted infections. Always use a barrier method of contraception during sex. Condoms and femidoms offer the most protection when used correctly and consistently. A diaphragm or cervical cap (used with a spermicide) may also help prevent gonorrhoea and chlamydia, but not other STIs. Get regular sexual health check-ups. This will help to ensure timely diagnosis and treatment of STIs. Screening for gonorrhoea and chlamydia, however, is not always part of a routine check-up. Tell the doctor or nurse if you want to be tested for chlamydia and gonorrhoea. Make sure you are tested for chlamydia and gonorrhoea before any procedure that opens the cervix (for example:abortion, IUD insertion, vaginal childbirth). Diagnosing PID Studies show that treatment of PID is most effective when started early – within two days of first noticing symptoms. Unfortunately, pelvic inflammatory disease is difficult to diagnose and this often delays treatment. There is no simple, standard procedure to test for PID, and because symptoms may be mild or non-existent, it can go unnoticed for months or years. Even when there are symptoms, many women are so used to experiencing discomfort or pelvic pain with their periods that abdominal pain (the main symptom of PID) may be dismissed – by themselves or their GPs – as nothing out of the ordinary. It may be only when pain becomes severe or incapacitating that women seek help or are taken seriously. Without a definitive test for PID, most cases are diagnosed based on reported symptoms (what you tell your doctor) and the results of an internal pelvic examination. This involves the doctor inserting two fingers into your vagina while pushing gently on your abdomen with the other hand. If this is painful for you, it is considered highly likely that you have PID. You may be given antibiotics immediately – a delay of just a few days may be enough time for the infection to cause serious damage. Your doctor may also want to confirm the diagnosis with other tests. Chlamydia and gonorrhoea screening This is done routinely at GUM clinics when PID is suspected, but may not be done automatically by your GP. The doctor (or nurse) will take a sample (swab) of mucus from your vagina, cervix and/or urethra. Some clinics and GPs may offer urine screening instead of, or in addition to, the swab tests. If the test results show signs of chlamydia or gonorrhoea, it will back up the initial diagnosis and mean you almost certainly have PID. But even if the test is negative, you may still have PID caused by another type of, or undetected, bacteria. Blood tests Blood tests may be used to support a diagnosis of PID. Some tests look for increased white blood cells – a sign that the body is fighting an infection. A positive result, however, doesn’t mean you have PID (your body may be fighting a different type of infection), and a negative result doesn’t mean you don’t have PID (if your body is fighting a very low-level infection it may not show up on the blood test). Another type of blood test looks for signs of pregnancy. Some symptoms of PID are the same as those of an ectopic pregnancy and misdiagnosis could be fatal. UltrasoundIn some cases, an ultrasound scan is used to look for swelling or an abscess (infected pocket of pus) in the internal reproductive organs. An ultrasound uses sound waves to produce an image of your internal organs and this may be done abdominally or vaginally. For an abdominal scan, the doctor simply moves the probe over your belly. The scan itself is not painful, but you need to have a full bladder during the procedure and this may be uncomfortable. If you have a vaginal scan, a small probe will be put into your vagina. You do not need a full bladder for this type of ultrasound, but the procedure may be a little uncomfortable. Laparoscopy A laparoscopy is a minor surgical procedure that enables the doctor to look directly at the internal organs, and if necessary, take a tissue sample to test for bacteria. Laparoscopy is considered the most reliable way to diagnose PID, but is generally only used as a last resort, when treatment is not working. Laparoscopy is done in hospital under general or local anaesthetic, and usually takes about 30 minutes. During the procedure, the doctor makes a small cut just below your belly button and inserts a very thin telescope (the laparoscope). Another small instrument is inserted to move your organs around. This may be inserted through a second incision above your pubic hair or through your vagina. The doctor can then look for signs of infection, such as swelling, inflammation or scar tissue. If a tissue sample needs to be taken, this will be done through an additional incision. As laparoscopy examines the outside of the organs, however, it may not detect infections inside the womb or low level infections that aren’t causing visible swelling. Magnetic Resonance Imaging (MRI) A recent study in Finland suggests that magnetic resonance imaging may be able to diagnose PID as accurately as laparoscopy, but without the need for surgery. MRI is not currently used to diagnose PID, but if other studies support its effectiveness, it may be a new way to help diagnose PID accurately and early. If you think your symptoms are not being taken seriously by your doctor, you may want to try a GUM clinic. They specialise in sexual health and genito-urinary medicine and are likely to have more experience of dealing with PID. See Resources for more information. Treating PID PID almost always involves more than one type of bacteria, and therefore is treated with a combination of at least two antibiotics. Specific combinations may vary, but treatment is likely to be:
Antibiotics prescribed for PID include ofloxacin, metronidazole, doxycycline, ceftriaxone (injection), and cefoxitan (injection) plus probenecid. There is some evidence to suggest that treatment with doxycyline and metronidazole only has lower cure rates than other combinations. If you are allergic to any of these antibiotics, tell your doctor. For any treatment to be effective, it is important to:
Treatment for women with HIV Women who are HIV-positive tend to have more severe symptoms of PID, but studies show that treatment with a standard course of intravenous antibiotics is just as effective as in women who do not have HIV. Side effects of treatment Some antibiotics may cause dizziness, nausea and headaches. Unfortunately there is not a lot you can do about this. Avoid alcohol and get as much rest as possible. Antibiotics may also cause vaginal thrush (yeast infection). Thrush can be treated with vaginal creams or pessaries, or with capsules taken by mouth. For more information on the treatment of thrush please visit the Women’s Health pages on Thrush. Self Help Heat. Heat may help to relieve pain and assist in the healing process. Take a hot bath or relax with a hot water bottle or heating pad on your abdomen. (Wait to be diagnosed before you apply heat as it can be dangerous if you have appendicitis.) Raspberry leaf tea. Raspberry leaf tea (not raspberry tea) may strengthen the reproductive system and help fight infection. Healthy diet. Eating well, avoiding alcohol and getting plenty of C, A, D and B vitamins will help your body fight infection. Acupuncture. Some women find that acupuncture helps relieve pelvic pain. Try to find a practitioner who has experience treating women with PID. Rest. Sleep and rest will help you recover from an episode of PID. Women with PID may be told they are imagining their symptoms or are overreacting to ‘normal’ period pains. This can be both physically and emotionally damaging. It may help to share your experiences with someone you trust.
PID — Complications and long-term problems Many women recover from PID without any lasting problems, but if the infection is not treated early or entirely, PID can lead to serious complications. Just one episode of PID increases a woman’s risk of chronic pelvic pain, ectopic pregnancy, infertility, and getting PID again. Recurrent PID — Some women develop PID time after time. This can happen if an infection hasn’t been completely cured or if you’ve been reinfected. Unfortunately, the more often you have PID, the more likely you are to get it again. By keeping track of what is going on in your life when infections occur, however, you may be able to identify what triggers the attacks. Some women, for example, tend to get PID when they are very stressed or tired, after a vaginal infection (such as thrush) or following sex. Once you’ve pinpointed possible triggers, you may be able to take steps to avoid further episodes. Abscess — Sometimes PID infections develop into an abscess (a pocket of infected fluid). An abscess can be particularly dangerous because it may not go away with antibiotic treatment, and if it bursts (ruptures), it can be life threatening. If you have an abscess that does not go away with antibiotics, your doctor may suggest surgery. Ectopic pregnancy — When PID develops in a woman’s fallopian tubes, it can turn the smooth lining of the tubes into scar tissue. This scarring can block the tubes, making it difficult for an egg to pass through them. If a fertilised egg gets stuck in one of the fallopian tubes, it may continue to grow as if it were in the womb. This is an ectopic pregnancy and is a potentially life-threatening situation. In some cases, the embryo may miscarry naturally, but if it continues to grow, the fallopian tube will burst, causing internal bleeding. The only way to stop this from happening is to terminate the pregnancy. It is estimated that one in ten pregnancies that occur after an episode of PID will be ectopic. If you have had PID and become pregnant, tell your doctor right away, so she or he knows you are at risk. Infertility — Scarring from PID may be so severe that it blocks the fallopian tubes entirely, making it virtually impossible for an egg to get through. It is estimated that one in five women who develop PID will be infertile as a result. When a woman has more than one episode of PID, her chances of becoming infertile are even higher. Some women, however, have become pregnant after being told their tubes were blocked, so if you don’t want to get pregnant, you should continue to use birth control. If you do want to have children, you may need to undergo in vitro fertilisation (IVF) and embryo transfer. Sometimes blocked or damaged tubes can be repaired with surgery, but the results are mixed and it may actually cause further scarring. Chronic pain — Scarring can cause pelvic tissues and organs to stick together, pulling and straining them, and this can be very painful. One in five women who have had PID develop chronic pelvic pain. The pain may be caused by scar tissue (adhesions) that developed before the PID was treated, or it may be that an infection or inflammation has not been cured completely. Some adhesions can be separated surgically and this may help to ease pelvic pain. Surgery Surgery is generally not necessary to get rid of PID, but if you have chronic PID or pelvic pain your doctor may recommend removing the damaged or infected organs. The procedures listed below are major operations and you may want to get a second opinion before going ahead with surgery. Ask your doctor for a full explanation of any suggested procedure, including risks, benefits and success rates. Salpingectomy This is the removal of one or both of the fallopian tubes. It will only stop PID if the infection is confined to the tube(s), and you may still develop PID in other organs. Salpingectomy is major abdominal surgery and may cause additional pelvic adhesions. If both tubes are removed, you will no longer be able to get pregnant naturally. Hysterectomy A hysterectomy removes the uterus (womb) and usually the cervix. A hysterectomy may reduce pelvic pain, and is likely to get rid of PID, but there is no guarantee. If the infection or scarring is outside of the womb, for example, a hysterectomy will be of no use. If your doctor recommends a hysterectomy, find out exactly which organs she or he intends to remove. Sometimes the fallopian tubes and ovaries are taken out during a hysterectomy and for many women this is a terrible surprise. A hysterectomy is major surgery and it will take a few months to recover fully. You will not be able to have children after a hysterectomy. See the Women’s Health online leaflet Hysterectomy for more information about this operation. Oophorectomy This is the removal of one or both ovaries, and is sometimes done at the same time as a hysterectomy. If both ovaries are removed, you will have a sudden, immediate menopause. PID — Resources and links
Clinics GUM clinics offer free, confidential services and do not require a referral letter. To find a GUM clinic near you, look in the phone book under your local health authority, or contact Women’s Health on 0845 125 5254 (Mon - Fri, 9.30am to 1.30pm), or look on the NHS website: www.playingsafely.co.uk or the fpa website: www.fpa.org.uk. If you prefer to be seen by a woman, call the clinic first and ask if they can arrange it. Books & further reading Pelvic inflammatory disease & chlamydia by Patsy Westcott (Thorsons, 1992) Self help and support |
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Written by Tamara Beus and published in printed format (2002) by Women's Health
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