Pelvic inflammatory disease: the facts

Unless PID is treated quickly, it could have drastic consequences for fertility, says Dr Lesley Hickin

Known as PID, pelvic inflammatory disease is caused by bacterial infection of the pelvic organs and surrounding tissues, including the uterus, Fallopian tubes and ovaries. Bacteria pass from the vagina through the cervix into the cavity of the uterus. From there they can ascend through the tubes to the ovaries and into the peritoneal cavity in which the pelvic organs are suspended by slings of tissue.

The bacteria most commonly responsible are chlamydia and gonorrhoea, two very common STIs (sexually transmitted infections), although it is thought that some bacteria which normally exist harmlessly in the vagina and bowel may be involved on occasion. The mechanism of this is not well known but it is thought that the normally protective mucus plug in the cervix becomes less effective during a period and at ovulation, enabling bacteria to pass through into the upper genital tract.

PID can occur after having a baby, a miscarriage or termination, and after an IUD (coil) has been fitted. Most commonly it happens after having unprotected vaginal sex with an infected partner.

Who is at risk?

  • Women with STIs, particularly chlamydia and gonorrhoea infection, are at greater risk of developing PID.
  • A previous episode of PID makes a woman more likely to develop a further episode because the tissues in the pelvis are already damaged.
  • Sexually active teenagers, who have easily damaged tissues, are more at risk than older women, as they also are of developing abnormal cells in the cervix.
  • The more sexual partners a woman has the more likely she is to be infected.

    What are the symptoms?
    PID can range in severity from a mild condition with few symptoms to a life-threatening illness. Not everyone will have symptoms from PID, particularly when it is caused by chlamydia, when there may be only minor symptoms or none at all, even though it can seriously damage the reproductive organs.

    The major symptoms otherwise are lower abdominal pain and abnormal vaginal discharge. Accompanying symptoms, such as painful sexual intercourse, pain in the upper abdomen, fever, and heavy or irregular vaginal bleeding, can also occur.

    How is it diagnosed?
    The doctor will ask about symptoms, how long they have been present and how severe they are. He or she will also ask some very personal questions about sexual partners, contraception and menstruation. It is important to be honest about these things so that the doctor can reach a diagnosis. Everything will be in complete confidence.

    After this, the doctor will examine you. This should include checking the abdomen to localise the pain, looking for fever, abnormal discharge and performing an internal (vaginal) examination. The doctor may use a speculum to examine the cervix, to look for signs of infection of the cervix by gonorrhoea, and take samples for bacteriological investigations.

    If the pain is very severe, the patient is generally very unwell, pregnant or in her teens, or there is some doubt about the cause of the symptoms, the doctor may advise hospital admission for a couple of days to have more intensive investigation and treatment. An ultrasound scan or a laparoscopy may enable the doctors to reach a faster diagnosis.

    How is PID treated?
    It is very important that treatment with antibiotics is commenced as soon as possible so that the least harm will be done to the pelvic organs. At least two antibiotics will be prescribed to cover all bacteria types. It is difficult to identify bacteria from the upper genital tract because they are fragile and do not survive for long outside the body (i.e. on a swab on the way to the laboratory). Several different bacteria may be responsible for the attack, especially if it is a recurring one.

    The symptoms may disappear before the course of antibiotics is finished, but it is very important to complete the course (usually at least ten days). A follow-up visit to the doctor should be made after two or three days to ensure the treatment is working, and hear the results of the tests.

    Many women with PID will have partners who have no symptoms themselves. Despite this, partners should be treated with antibiotics, because men can often carry these bacteria unknowingly and could cause re-infection.

    What are the complications?
    Many women become infertile each year as a result of PID, and a large proportion of the ectopic (tubal) pregnancies occurring each year are a result of pelvic infection.

    Women with recurrent episodes of PID are more likely to develop scarring of the Fallopian tubes and subsequent infertility than women with a single episode. Infertility occurs in about 20 per cent of women with PID. A woman who has had PID is six to ten times more likely to have an ectopic pregnancy, and this is almost always life-threatening to the foetus and sometimes to the mother.

    In addition, untreated PID can lead to chronic pelvic pain and scarring in about 20 per cent of cases.

    How can you protect yourself?

  • Report any symptoms of pelvic pain, unusual discharge and irregular or heavy bleeding to your doctor.
  • If you are at high risk (see above) then protect yourself against STIs by using male condoms, which almost completely prevent gonorrhoea and partially prevent chlamydia infection.
  • If you are in a high risk group then you should be screened for chlamydia infection regularly. A recent study showed a staggeringly high number of teenagers in Nottingham carried chlamydia.
  • Ensure that your sexual partner is treated at the same time as you.

    The future
    Newer and more sensitive testing methods are needed in general usage to detect chlamydia and gonorrhoea. Research is ongoing to develop a vaccine and topical antimicrobial treatment. Education about the subject is necessary at an early age, and teenagers should have easier access to confidential and expert advice on sexual health matters.