Pelvic inflammatory disease
Introduction
Pelvic inflammatory disease (PID) is a bacterial infection of the upper female genital tract, including the womb fallopian tubes, and ovaries.
Most cases of PID are caused by an infection in the vagina or the neck of the womb (cervix) that has spread to the reproductive organs higher up.
Many different types of bacteria can cause PID, but most cases are the result of a Chlamydia or gonorrhoea infection (see Causes for more information).
What happens?
When infection spreads upwards from the cervix (entrance to the womb), it causes one or more of the following:
- endometriosis: inflammation and infection of the endometrium (womb lining),
- salpingitis: inflammation and infection of the fallopian tubes
- parametritis: inflammation and infection of the tissue around the womb,
- oophoritis: inflammation and infection of the ovaries,
- an abscess: a pocket of infected fluid in the ovary and fallopian tube, and
- pelvic peritonitis: inflammation and infection of the peritoneum (lining of the inside of the abdomen).
If you develop salpingitis, the lining of the fallopian tubes swells and the already narrow canals become even narrower. This means that fertilised eggs may not be able to move along normally, increasing the risk of ectopic pregnancy (a pregnancy that occurs outside the womb) and infertility (see Complications for more information).
Who is affected?
PID most commonly develops in sexually active women between the ages of 15 and 24.
The disease is fairly common and is the reason for 1 in 60 visits to GPs by women under 45. Many more women with PID experience few or no symptoms.
Outlook
If diagnosed at an early stage, PID can be treated quickly and efficiently with antibiotics. However, if left untreated, it can lead to more serious long-term complications such as an ectopic pregnancy.
Further infection is common. After a first episode of PID, one in five women has more episodes, mostly within two years. Repeated episodes of PID are associated with an increased risk of infertility.
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Symptoms
The symptoms of pelvic inflammatory disease (PID) are fairly general, which means that the condition can be difficult to diagnose.
The warning signs include:
- pain around the pelvis or lower abdomen,
- discomfort or pain during sexual intercourse that is felt deep inside the pelvis,
- bleeding between periods and after sex,
- unusual vaginal discharge, especially if it is yellow or green,
- fever and vomiting, and
- pain in the rectum (back passage).
You may have PID without being aware of it. Sometimes, there are no symptoms at all or, if there are, they may not be obvious. For example you may only experience mild discomfort.
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Causes
Pelvic inflammatory disease (PID) is an infection. If a woman develops an infection in her vagina, the bacteria causing the infection can move upwards, through the cervix (the entrance to the womb), into the womb and spread to the fallopian tubes and ovaries.
PID is often caused by more than one type of bacterium and it can sometimes be difficult for doctors to pinpoint which bacteria are responsible. Therefore, a combination of antibiotics may be prescribed so that a variety of bacteria can be treated.
Chlamydia and gonorrhoea
Many different types of bacteria can cause PID. However, the most frequent causes are two common sexually transmitted infections: chlamydia and gonorrhoea.
In the UK, the bacteria that cause chlamydia (chlamydia trachomatis) are responsible for between 50-65% of the cases of PID. The bacteria that cause gonorrhoea (neisseria gonorrhoeae) are responsible in about 14% of cases. About 8% of women with PID are infected with both chlamydia and gonorrhoea.
Other causes
Sometimes, the infection that leads to PID may start as a result of bacteria introduced into the vagina or upper genital tract during childbirth, an abortion or miscarriage, or a procedure to take a sample of tissue from the inside of the womb(endometrial biopsy).
In rare cases, PID can develop as a result of appendicitis, treatment following an abnormal cervical smear or after the fitting of an IUD (intrauterine device or coil).
In some cases, the cause of the infection that leads to PID is unknown. Such cases may be the result of normally harmless bacteria found in the vagina. These bacteria can sometimes get past the cervix and into the reproductive organs. Although harmless to the vagina, this type of bacteria can cause infection in other parts of the body. Infection in this way is most likely to happen when there has been damage to the cervix, or if you have had PID before.
Who is most at risk?
Anyone can get pelvic inflammatory disease, but you are more likely to get it if you:
- are under 25,
- started having sex at a young age,
- have more than one sexual partner,
- have a recent new partner, and
- have a history of sexually transmitted infections.
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Diagnosis
There is no single test for diagnosing pelvic inflammatory disease (PID).
Your doctor will diagnose PID based on your symptoms and on a gynaecological examination. When your doctor examines you, they will look for tenderness in your pelvic region and an abnormal vaginal discharge.
The doctor will usually take swabs from inside your vagina and cervix, which will be sent to the laboratory to try and identify the type of bacteria that is causing the infection. However, a swab test cannot be relied on to diagnose PID as some women with PID have a negative swab result.
Because PID is difficult to diagnose by the symptoms alone, you have a blood test, or have an ultrasound scan. Scans can identify severe PID but will not show up mild disease. It is, therefore, possible to have a normal scan and still have PID.
In some cases, a laparoscopy (keyhole surgery) may be used to diagnose PID. A laparoscopy is a minor surgical procedure where two small cuts are made in the abdomen. A thin microscope is inserted so that the doctor can look at the internal organs and, if necessary, take tissue samples. This is usually only done in more severe cases where there may be other possible causes of the symptoms, such as appendicitis.
Admission to hospital
You may be urgently admitted to hospital if:
- you are pregnant, especially if there is a chance you may have an ectopic pregnancy,
- your symptoms are severe (such as nausea, vomiting and a high fever),
- you have signs of pelvic peritonitis (inflammation of the inside lining of the abdomen),
- an abscess is suspected, or
- you may need emergency surgery, for example for appendicitis.
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Treatment
If diagnosed at an early stage, pelvic inflammatory disease (PID) can be treated quickly and efficiently. However, if it is left untreated, it can lead to more serious, long-term complications (see Complications section for more information).
Antibiotics
A combination of at least two antibiotics is usually prescribed to treat PID. This is because PID often involves several different types of bacteria.
Without running tests, it can be hard for doctors to identify the exact bacteria responsible, and so a combination of antibiotics may be initially prescribed so that a variety of bacteria can be treated. Quick and efficient treatment of PID is essential for minimising the risk of infertility.
If your doctor is able to pinpoint the bacteria, then your antibiotics may be changed accordingly. Antibiotics that are commonly prescribed to treat PID include ofloxacin, metronidazole, ceftriaxone and doxycycline.
You will usually have to take the antibiotics for 14 days. It is very important that you complete the entire course of antibiotics, otherwise the treatment may not be effective.
In particularly severe cases of PID, you may have to be admitted to hospital where you will receive antibiotics intravenously (through a drip in your arm).
Surgery
The bacteria that cause PID can leave scar tissue and collections of infected fluid (abscesses) on the lining of your Fallopian tubes. This makes it very hard for an egg to pass along it.
The longer PID is left untreated, the more likely scarring will occur. Prompt treatment is essential for minimising the risk of damage to the Fallopian tubes and other reproductive organs.
Studies suggest that even delaying treatment by a few days can increase the risk of impaired fertility. However, most women get pregnant without problems after a single episode of PID.
Laparoscopy
Sometimes, blocked or damaged tubes can be repaired during a laparoscopy (keyhole surgery), where the abnormal tissue on the lining of the tubes is removed. However, this can sometimes cause further scarring and may not always restore fertility.
Salpingectomy
A more extreme form of surgery is a salpingectomy. This involves the removal of one or both of the Fallopian tubes to stop the spread of further infection.
This is only to be considered as a last resort, as the removal of both Fallopian tubes will mean you will no longer be able to get pregnant naturally.
The longer treatment for PID is delayed, the more likely it is that the Fallopian tubes, and other reproductive organs will be permanently damaged.
If the tubes are so damaged that it is impossible to get pregnant naturally, some people will be helped by IVF (in-vitro fertilisation).
Avoiding sex and contacting sexual partners
Avoid having sexual intercourse until you have completed your treatment. Having sex can interrupt the healing process.
Any sexual partners you have been with in the six months before your symptoms started should be tested and treated to stop the infection recurring. If you have not had a sexual partner in the last six months, contact your most recent partner.
Current and recent partners should be seen in a sexual health clinic for testing and treatment. Do not have sex with a previous partner unless you are sure that they have received treatment.
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Complications
The main complications that can occur from pelvic inflammatory disease (PID) are outlined below.
Recurrent pelvic inflammatory disease
Recurrent pelvic inflammatory disease is where a woman develops repeated episodes of PID. The more often a woman gets PID, the more likely she is to get it in the future.
The condition can reoccur if the initial infection is not entirely cured or because a sexual partner has not been tested and treated.
If an initial case of PID damages the cervix, it can become easier for bacteria to move into the reproductive organs in the future, making you more susceptible to developing the condition again. Repeated episodes of PID are associated with an increased risk of infertility.
Abscesses
Sometimes, PID can cause abscesses on the lips to the entrance of the vagina (Bartholin's cysts) and in the Fallopian tubes and ovaries. An abscess is a collection of infected fluid. It can usually be treated with antibiotics. If an abscess does not respond to antibiotics you may require surgery.
It is important that abscess inside the pelvis are either treated or removed, as an abscess that bursts can be potentially life threatening.
Ectopic pregnancy
The word ectopic means in the wrong place. In a normal pregnancy, the fertilised egg implants in the womb lining. An ectopic pregnancy is one which occurs outside of the womb.
Over 95% of ectopic pregnancies occur in a Fallopian tube. If PID develops in the Fallopian tubes, it can scar the lining of the tubes, making it more difficult for eggs to pass through. If a fertilised egg gets stuck and begins to grow inside the tube, it can cause the tube to burst, which can sometimes lead to severe internal bleeding. Ectopic pregnancy is a potentially fatal condition.
Infertility
It is estimated that one in five women become infertile as a result of PID. This means they will be unable to get pregnant naturally. PID can make a woman infertile by scarring the Fallopian tubes so severely that it makes it virtually impossible for the egg to travel down into the womb. Delaying treatment for PID can increase your chances of becoming infertile.
If you want to get pregnant after becoming infertile from PID, you could consider an assisted conception technique such as In-Vitro Fertilisation (IVF). With IVF treatment, eggs are surgically removed from a woman's ovaries and then fertilised with sperm in a laboratory, before being planted into the woman's womb. IVF does not have a very high success rate. For more information, see IVF.
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Prevention
The most effective way to prevent pelvic inflammatory disease (PID) is to protect yourself from sexually transmitted infections. This means using a barrier contraceptive, such as a condom, femidom or cervical cap. Barrier contraceptive methods, used consistently and carefully, reduce (but do not remove altogether) the risk of getting a sexually transmitted infection.
It is also important to get regular sexual health check-ups at your local sexual health clinic. Get a check-up if you change your partner or have unprotected sex with a casual partner, or if you think your partner has being having sex with someone else. Find your local sexual health clinic.
Have a sexual health check if you have had sexual contact with someone you think may have been infected with either a sexually transmitted infection or PID.
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