What Is Pelvic Inflammatory Disease?

Overview

Pelvic Inflammatory Disease (PID) is an infection caused by a wide variety of bacteria  which affects parts of the female reproductive system namely, the womb, the fallopian tubes, and the ovaries.¹ Given this, it is clear that PID is a disease that only affects women and majorly women that are sexually active.¹

Given that PID is an infection that majorly affects women that are sexually active, there have been misconceptions that PID is a sexually transmitted infection (STI). Yes, sexual activity and the number of sexual partners greatly increase your risk of getting PID but cases of PID have also been documented in individuals prior to their sexual debut.¹

How common is PID?

One of the drawbacks of the Covid-19 pandemic is that it prevented the collection of epidemiological data on various infections and diseases as the world focused on all things Covid-19.

PID is generally underreported because most people who have it have no symptoms unless complications occur.³ 

The last report by Public Health England on the rate of PID in England states that a positive diagnosis of  PID was made in approximately 176 women between the age of 15 to 44 years in GP surgeries for every 100,000 women screened in 2011. In hospital settings, approximately 241 cases of PID were confirmed per 100,000 women between the age of 15 to 44 years that were screened for PID in 2011.²

Across the pond in the US, a diagnosis of PID is made in over one million women every year and the prevalence of PID appears to be higher in women who have a previous history of STI.⁴

Causes of pelvic inflammatory disease

The bacteria mostly associated with PID include Chlamydia trachomatis and Neisseria gonorrhoeae, the bacteria that cause chlamydia and gonorrhea respectively. PID can also be caused by other sexually transmitted bacteria such as Mycoplasma genitalium^.2

When these bacteria are introduced into the vagina following close sexual contact, they travel up the vagina and cervix to the neck of the womb. These bacteria can also affect the pelvis which can cause pelvic pain.⁵ 

Additionally, bacteria that normally live in the vagina can travel up  through the cervix to cause PID. This explains why PID, although largely caused by bacteria that are sexually transmitted, is not considered a sexually transmitted disease.¹

Signs and symptoms of pelvic inflammatory disease

Most cases of PID usually do not cause any symptoms in affected individuals unless complications occur.¹

In individuals with PID that present with symptoms, these usually include:

• Dysuria
• Pelvic pain or pain felt around the lower abdomen 
• Pain or discomfort during sex 
• Bleeding during sex or in between periods
• Heavy and/or painful periods
• Abnormal vaginal discharge which is accompanied by an offensive smell 

In severe cases, women with PID may present with high-grade fever, severe lower abdominal pain, nausea, and/or vomiting.

Management and treatment for PID

The earlier PID is diagnosed, the earlier it is treated which prevents the development of complications. Unfortunately, if complications are present at the time of diagnosis of PID, the damage done by the infection is permanent and can not be reversed.²

PID is caused by bacteria thus it is no surprise that antibiotics, the medicines used to treat bacterial infections are used to treat PID. The antibiotic treatment regimen for PID involves the use of a combination of antibiotics either given orally for a number of days, usually 14 days, or intravenous antibiotics given through a vein. The decision on which treatment regimen to opt for depends on the severity of the infection.²

Intravenous treatment is usually recommended in women who:

• Are pregnant - pregnant women with PID are at high risk of preterm delivery which can negatively affect the pregnancy
• Show signs of severe illness
• Are confirmed to have tubo-ovarian abscesses  

During treatment, it is generally advisable to avoid all sexual relations till the course of antibiotics is completed and when symptoms, if any, resolve. In addition, the partners of affected individuals are often tested for STIs and treated if positive.⁶

Diagnosis of PID

PID can be diagnosed by taking a medical history which entails asking about your signs and symptoms, and previous STI or PID diagnosis.^2,4 In addition, your GP or healthcare professional can carry out a physical exam where a sample of fluid from the vagina and cervix is taken and sent off for laboratory confirmation^.1 A sample of your blood may also be taken to check for indicators of inflammation and/or infection in the blood^.2

A positive diagnosis of PID usually includes:²

• Evidence of Indicators of inflammation and infection in the blood such as elevated C-Reactive Protein (CRP) and elevated Erythrocyte Sedimentation Rate (ESR)
• Oral temperature > 38.3 degrees centigrade
• Abnormal discharge from the cervix and cervix tenderness during the examination
• Laboratory confirmation of infection with any of the bacteria that can cause PID from samples taken from the vagina and cervix

Risk factors

PID is more common in individuals that are sexually active as you are more likely to come in close contact with bacteria that can cause the infection that leads to PID.⁵

Your risk of getting PID increases if:⁵

• You're sexually active and are 25 years of age or younger 
• You have a new sexual partner or partners
• You've had PID or an STI in the past
• You've had an abortion recently 
• You've had a recent operation on the womb
• You’ve had an Intrauterine Device (IUD) inserted recently
• You practice douching

Abortion,  operations on the womb, the insertion of an IUD and douching are all procedures that can introduce PID-causing bacteria to parts of the female reproductive system where they can cause infection.

Complications

PID usually does not cause any symptoms and is usually detected when the infection has resulted in complications that present with signs and symptoms.²Unfortunately, some complications of PID are irreversible which further stresses why regular screening and safe sex practices are key to reducing your risk of PID and its devastating complications.

Complications associated with PID include: ⁴,^5,6

• Infertility 
• Blocked fallopian tubes due to scarring inside and outside the fallopian tubes. This can increase the risk of ectopic pregnancy. Ectopic pregnancy is a medical emergency that can be fatal in a few cases.
• Long-term lower abdominal pain

Complications are more likely in individuals who have had PID for a long time and did not get treatment and in those with repeated episodes of PID. It's not all gloom and doom though as a large number of  women with PID that access treatment can get pregnant and have healthy babies.

FAQs

How can I prevent PID

So how do you reduce your risk of getting PID? By practicing safe sexual habits such as:^1,4,6

• Using condoms each time you have sex with a new non-exclusive partner until the person gets screened for STIs
• Reducing the number of sexual partners you have, most STIs do not present with symptoms especially in males so most males with STIs are not aware they are infected
• If you are undergoing a procedure at the gynecologist i.e insertion of an intrauterine device (IUD) or pregnancy termination, screen for STIs beforehand 
• If you're sexually active, ensure that you screen for STIs regularly, especially for chlamydia and gonorrhea.  If you are in the UK, you can do this by visiting your local sexual health clinic previously known as the Genitourinary Medicine (GUM) Clinics

How common is PID

The last report by Public Health England on the rate of PID in England states that 176 diagnoses of PID were made for every 100,000 women between the age of 15 to 44 years screened for PID in GP surgeries and 241 for every 100,000 of women between the age of 15 to 44 years screened in hospital settings for the year 2011.³

Is pelvic inflammatory disease contagious

The bacteria that cause PID can be transferred between sexual partners. This explains why partners of women with PID are encouraged to get tested and treated.  Additionally, because these bacteria can be passed between sexual partners, to reduce the risk of PID, it is recommended that women should use condoms with new partners till the partner is cleared of any STI.¹

When should I see a doctor

Make an appointment to see your GP or local sexual health clinic if:¹

• You are experiencing any of the PID symptoms mentioned above
• You had PID in the past and are worried you may have it again
• If you are experiencing any of the symptoms above and have a new sexual partner 

Summary

PID is an easily treatable infection, problems usually occur when complications occur due to not seeking treatment on time or not treating the infection effectively. The complications associated with PID mainly affect fertility and thus can have detrimental effects on the mental health of women affected.

Imagine being told that your chances of having children are unlikely just because you did not treat an infection you probably thought was nothing serious or you don't even know you had. The take-home message with PID and all conditions in general is to seek medical attention when things don't feel right.

In the case of PID which usually does not present with symptoms, regular STI screening in individuals who are sexually active, especially if you do not practice monogamy, will ensure that infections likely to cause PID are picked up early and treated.

In rare instances, non-sexual contact can cause PID. This happens when bacteria from what we call the normal flora of the vagina, that is bacteria that are normally present in the vagina, go up through the cervix to cause PID. This usually occurs during gynecological procedures such as IUD insertion, vaginal birth, abortion, and after douching.