Pelvic inflammatory disease

Estimates suggest that up to 15 per cent of women will have suffered from an attack of PID by the time they are 30 years old. Few, however, realise the consequences of letting the condition go untreated.

Pelvic inflammatory disease (PID) is an infection of the uterus, Fallopian tubes or the tissues surrounding them, and is a condition that all women should be aware of. It can lead to very serious long-term complications – infertility, and in a small number of cases death – if it goes untreated.

Who gets it?

PID is very common. Evidence from America puts the annual incidence of PID at 1.5 per cent in 18-year-olds and 0.5 per cent in 25-year-olds. One large study, however, found that by the age of 30, 15 per cent of women had experienced the infection and of these 25 per cent turned out to be infertile as a direct result.

What causes it?

PID, like chlamydia and cervical cancer, is most strongly associated with heterosexual sexual intercourse. It is extremely rare in nuns and lesbians and much more common in women with multiple male partners.

Fortunately, recent evidence suggests that the rate of PID is now falling, especially among the young. Specialists in the field of sexually transmitted diseases think that this has come about as a result of the publicity given to ‘safer sex’. They cite in particular the increased use of condoms in response to the threat of HIV infection, and improvements in diagnostic techniques which allow for much more accurate tracing and treatment of sexual contacts.

Most cases of PID are due to either neisseria gonorrhoea or chlamydia infection, but almost any bacteria that can find its way into the vagina has the potential to cause PID. Usually the infection starts in the vagina and works its way up through the cervix and uterus, then along the Fallopian tubes to the ovaries and beyond.

As well as sexual activity, there are a number of other factors associated with an increase in the incidence of infection, though so far there is no evidence to suggest that any of them actually cause it.

• Age: Population studies have shown time and time again that PID is commonest in teenagers. The reason for this higher incidence is not yet known, but indications are it may be due to a higher level of sexual activity and a higher number of sexual partners at this time of life, an immature immune system or a reluctance to see medical help at an early stage because of embarrassment.

• Contraception: Using the coil has been shown to increase the risk of PID, while barrier methods – condoms, the cap – and the Pill actually reduce the risk, bringing it down below that run by people who do not use contraception at all. Many infections associated with the use of the coil occur in the first few weeks after insertion and gynaecologists admit they are usually the result of contamination at the time of insertion. Gynaecologists now routinely prescribe a course of antibiotics when they insert a coil and this does seem to decrease the risk. It is thought that the Pill, by thickening the mucus in the cervix, protects the uterus from invasion by infection.

PID after sterilization is almost unheard of, presumably because the bacteria are unable to negotiate the clips used to seal the Fallopian tubes.

• Untreated partners: Countries where the medical profession doesn’t routinely treat the male partners of women who present with PID or where they don’t trace sexual contacts and invite them to have treatment have a much higher incidence of PID than countries that do.

What are the symptoms?

One of the reasons that PID is so common and is associated with so many complications is that it is notoriously difficult to diagnose. The usual symptoms – pain, fever, irregular bleeding, painful intercourse and a vaginal discharge – can be caused by numerous other infections. Even microbiological swabs, because they are taken from inside the vagina and not from further up in the pelvic cavity, are often misleading.

The best way to make a diagnosis is to examine the uterus, tubes and surrounding structures through a laparoscope (a telescope inserted just below the navel). In cases where a laparoscopy has proved inconclusive, small amounts of fluid can be drawn from the abdominal cavity and looked at for the presence of infection. This sounds like an uncomfortable process, but in fact it is not as bad as it sounds.

In practice, of course, most doctors would not contemplate using such an invasive technique, preferring to rely on their clinical judgement rather than risking a general anaesthetic.

Important clues to the diagnosis of PID can be found by careful vaginal examination. There is often generalized tenderness but this is usually worse high up on both sides of the vagina. ‘Cervical excitation’ – severe pain when the cervix is manipulated from side to side – is often the only external sign of an infection and even this is sometimes absent in cases of PID.

Because of the various potentially disastrous consequences of not treating PID, most doctors employ what they call a ‘high index of suspicion and a low threshold for treatment’. In other words, if there is the remotest possiblity that they might be dealing with a case of PID, they will treat it early and aggressively.

How is it treated?

Most cases of PID are treated at home. Only women who are very severely affected or women in whom other conditions, such as appendicitis or ectopic pregnancy, are present are admitted to hospital.

Most cases of PID, even if they start off as simple infections caused by a single bacteria, involve many different germs by the time they are treated. Most doctors will use a combination of two or more antibiotics but some drugs, such as ofloxacin, can be used on their own.

Whatever is used and whether it is given by injection or by mouth, the course is longer than is usual for less serious infections. A three-week course is commonplace.

Men often harbour the infection without knowing it. For the treatment to be effective it is vital that both partners are treated simultaneously and in addition many gynaecologists would advocate using condoms for at least a week or two after finishing the antibiotics.

Even after treatment is started, PID can still be painful, so powerful analgesic painkillers such as codeine or pethidine are often necessary until the inflammation starts to decline.

Treatment of PID in a coil user is not complete until the coil has been removed. Left in place it is unlikely that the infection will ever clear. In some circumstances it may be possible to insert a new coil a few weeks later but most doctors would suggest using another form of contraception, possibly the Pill, which is known to decrease the risk of further infection.

The human body has spent millions of years evolving defences against infections and it is likely that in the majority of cases, PID would eventually retreat of its own accord. Unfortunately a very significant proportion of cases rapidly progress to an acute, sometimes fatal, abscess stage which requires urgent surgical intervention. If PID develops this far a complete pelvic clearance in which the uterus, tubes and ovaries are removed is usually necessary.

Happily the majority of cases do not end so disastrously. They either settle partially and become chronic-low-grade infections of the tubes and ovaries or they can seem to abate completely but leave the pelvic organs so scarred that pregnancy becomes technically impossible.

Twenty-five per cent of women who suffer from PID once will suffer another attack even if they become celibate – a sign that even after the best treatment it may lay dormant.

Another 25 per cent, as a direct result of the scarring of the tubes that PID can cause, will become infertile. One study put the risk of such scarring as high as 90 per cent. Even if this figure is too high, the majority of ectopic pregnancies can be traced to previous episodes of PID.

Even if all of these complications are avoided and a normal pregnancy occurs it may not all be plain sailing. In a recent study nearly half the women who had had PID went into premature labour. To keep PID at bay and under control women should ensure that they are examined if they notice signs of infection.

How to avoid PID

Celibacy. There are cases of nuns having PID, just as there are cases of Bishops contracting syphilis or rabbis having pork tape worms, but they are jolly rare!

Safer sex. Monogamous sex with a monogamous partner is the best protection. Failing that, condoms or non-penetrative sex are nearly 100% safe.

Delaying sexual activity. The earlier sexual activity is undertaken, the greater the risk.

Choosing contraception carefully. Barrier and hormonal methods offer the best protection. The coil actually increases the risk of infection.

Giving up smoking. The association is far from clear, and it may not be a direct, causal link, but smokers have a greater chance of developing PID.

Avoiding vaginal douching. Vaginal douching forces bacteria into the uterus and predisposes women to PID.

Posted in Health, Sexual Health Problems