Unique to Women
Pelvic Inflammatory Disease
|I had been complaining of the same problem— pain in my lower right abdomen—for a couple of years. I had severe menstrual irregularities, fevers, bleeding between periods, bleeding after intercourse, pains, and general malaise. Several times I was treated with antibiotics, which brought only some temporary relief. Never was the issue resolved as to what was causing this. Never were my sexual partners or practices mentioned.|
Pelvic inflammatory disease (PID) is a general term for an infection that affects the lining of the uterus (endometritus), the fallopian tubes (salpingitis), and/or the ovaries (oophoritis). It is caused primarily by sexually transmitted infections that spread up from the opening of the uterus to these organs (see Chapter 11, “Sexually Transmitted Infections”). Nearly 1 million women in the United States develop PID every year, and 300,000 women are hospitalized for it. This may be a low estimate, because PID is underdiagnosed.
The primary symptom is pain in the lower abdomen. It may be so mild that you hardly notice it, or so strong that you may not even be able to stand. You may feel tightness or pressure in the reproductive organs, or an occasional dull ache. Part of the reason PID is so underdiagnosed is that women may also have some, most, or none of these other symptoms: abnormal or foul discharge from the vagina or urethra, pain or bleeding during or after intercourse, irregular bleeding or spotting, increased menstrual cramps, increased pain during ovulation, frequent or burning urination, inability to empty the bladder, swollen abdomen, sudden high fever or low-grade fever that comes and goes, chills, swollen lymph nodes, lack of appetite, nausea or vomiting, pain around the kidneys or liver, lower back or leg pain, feelings of weakness, tiredness, depression, and diminished desire to have sex.
The intensity and extent of the symptoms depend on which microorganisms are causing the problem, where they are located (uterus, tubes, lining of the abdomen, etc.), how long you have had PID, what if any antibiotics you have taken, and your general health. Doctors characterize PID as acute, chronic, or silent (when symptoms are not noticeable).
Most cases of PID are caused by microorganisms responsible for sexually transmitted infections. They can get into the body during sexual contact with an infected man or woman.18 If you are carrying these microorganisms, certain procedures or reproductive events can push them farther into your body, including miscarriage, childbirth, abortion, or other procedures in involving the uterus, such as endometrial biopsy, hysterosalpingogram (X-ray of the reproductive tract), IUD insertion, or donor insemination. If you have chronic PID and antibiotic treatment doesn’t help, your sexual partner(s) may be reinfecting you. Men can be carrying the organisms that can cause PID without having symptoms, so they must be tested and treated, too, and they should use a condom during intercourse.
The risk for developing PID is higher if you are exposed to infected secretions—especially infected semen—during menstruation and ovulation, when your cervix is more open and your mucus is more penetrable. In some parts of the United States, gonorrhea still causes most PID. In other areas, chlamydia is more often the cause of PID. Current guidelines recommend annual chlamydia screening for women age twenty-five and under who are having sex, to find and treat this infection before it causes PID.
The complications of PID can be very serious. If untreated, PID can turn into peritonitis—a life-threatening condition—or into a tuboovarian abscess. It can affect the bowels and the liver (causing perihepatitis syndrome). Months or years after an acute infection, infertility or ectopic pregnancy can result if your fallopian tubes were damaged or clogged by scar tissue. PID can also cause chronic pain from adhesions or lingering infection. In the most extreme cases, untreated PID can result in death.
Because so much PID is caused by sexually transmitted organisms, preventing PID involves preventing sexually transmitted infections. You can reduce your risk by using condoms and engaging in safer sex practices. For more information, see Chapter 11, “Sexually Transmitted Infections.”
If you could know right away exactly which organisms were causing your PID, you could get the right antibiotics. But pinpointing the organisms often takes some tests that may be expensive and not readily available. Sometimes organisms infecting the uterus and fallopian tubes don’t show up in a cervical culture. You may be told that your chronic cystitis is caused by trauma to the urethra during intercourse when it’s really a sign of PID, or that you got infected by wiping yourself from back to front, when you really have a sexually transmitted infection. You may be told that you have a spastic colon or an emotional, not a physical, problem, when that is not true. Try to have your situation thoroughly assessed, particularly if symptoms persist despite treatment, or seek a second opinion.
Blood tests can help indicate whether you have an infection but won’t always tell you which one. Sometimes an endometrial biopsy can find hard-to-culture organisms, but if it is not done carefully, this procedure can spread germs from the cervix and vagina to the uterus. In some cases, ultrasound, including vaginal ultrasound, may be useful. A definitive diagnosis often requires laparoscopic surgery.
Medical Treatments for PID
Most experts seem to agree that since your health and fertility are at stake, you should start treatment while waiting for test results. Both you and your partner must be treated. If your partner continues to carry the microorganism(s), you will be reinfected. Taking the wrong drugs can make organisms more difficult to get rid of; however, the practical strategy is to begin treatment, then adjust it according to what cause is found. Once you start taking antibiotics, you cannot get an accurate culture again until at least a couple of weeks after you stop taking them.
Therapy lasts at least ten to fourteen days. You should receive two different kinds of antibiotics, since more than one organism may be involved. Remember to take all your antibiotics, even if your symptoms are gone, so that antibiotic-resistant strains of microbes will be less likely to develop. (See the Centers for Disease Control and Prevention website for more information about antibiotic resistance.) Antibiotics can cause yeast overgrowth in the vagina, so you may need something to keep the yeast in check while trying to cure the much more serious PID (see “Yeast Infections,” p. 637).
Many experts recommend that all women with PID be hospitalized for treatment, but not all physicians follow these recommendations. Most women are hospitalized in the event of an acute attack, to get intravenous (IV) antibiotics. If you’re still not cured, it may be because you got the wrong antibiotic, have a pelvic abscess, or were reinfected by a partner. You may be urged to have a hysterectomy if the doctor thinks that PID has damaged your pelvic organs beyond repair. Also, emergency hysterectomies are done in some cases of acute PID (for example, when an abscess ruptures). If the infection is in your urinary tract, as it often is, then hysterectomy does not eliminate it. Hysterectomy is rarely necessary for PID, except in cases of persistent, debilitating PID.
Avoid intercourse until you have felt completely well through an entire monthly cycle and your partner(s) have had negative test results for all STIs. You can have a recurrence of PID months after the initial infection is cleared up, particularly if you don’t keep up daily health routines or are under too much stress.
Excerpted from the 2011 edition of Our Bodies, Ourselves. © 2011, Boston Women's Health Book Collective.
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