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Articles

Pelvic Inflammatory Disease (PID)

Introduction

What should I know about PID?

The term pelvic inflammatory disease (PID) usually refers to an ascending infection of the endometrium, (the membrane that lines the uterus) and/or fallopian tubes, (the tube that connects the ovary to the uterus). These infections are sometimes considered primary meaning that they occur spontaneously, usually sexually transmitted, or secondary meaning that they come as a result of something else such as surgery, insertion of an intrauterine device, or termination of pregnancy. (1) Worldwide, PID is a leading cause of infertility, and in the United States, it is considered responsible for the recent upswing in ectopic pregnancy. (2)

Pelvic inflammatory disease is almost exclusively a disease of sexually active women and may be of the chronic or acute type. Chronic PID caused by Mycobacterium tuberculosis has become uncommon in industrialized countries, however, PID caused by Chlamydia trachomatis is thought to be common. In general, first episodes of acute PID are likely to be caused by sexually transmitted pathogens. These pathogens are less often the cause in women with intrauterine devices, and/or invasive diagnostic or therapeutic procedures. Infections due to use of IUD or diagnostic procedures tend to be caused by ascending infection from the vaginal area.

The term, pelvic inflammatory disease has been used to describe an entire group of infections including simple cervicitis, to endometritis, to salpingitis, (inflammation of the fallopian tubes), to pelvic peritonitis, and finally to generalized peritonitis, perihepatitis, or pelvic abscess. The distinctions may be important, however, since confirmed cases of salpingitis, or inflammation of the fallopian tubes, is most frequently associated with long-term disease states. These disease states include infertility, ectopic pregnancy due to tubal damage, chronic pelvic pain, and sometimes recurrent PID. Sometimes the inflammation of the fallopian tubes (salpingitis) results in infertility in up to 13 percent of women following a single episode of PID, and in up to 75 percent of women after three or more episodes of PID. (3) The risk of ectopic pregnancy is increased approximately eight fold after one or more episodes of PID. (4)

Approximately 85 percent of all cases of acute PID occur by sexual transmission in females of reproductive age, with another 15 percent following procedures requiring the use of some type of instrument such as those used in IUD insertion, abortion, or dilation and curettage. (5) , (6) Acute PID develops in 1 percent of sexually active young women annually and causes more morbidity in women (15 to 25 years of age) than all other serious infections combined. (7) , (8)

There are several factors that seem to be implicated in the upward spread of infection in PID. Some of these include: attachment to sperm that migrate upwards into the tubes; use of an IUD; vaginal douching; menstruation; and the presence of thin cervical mucous which cannot provide the needed protection. It is important that a person be diagnosed and receive treatment early on in the disease in order to prevent the damage to the fallopian tubes. It is difficult for a physician to determine the damage to the fallopian tubes because there are really no diagnostic tests that can be used. Currently, only the use of a device called a laparoscope allows the clinician to determine damage and it is not practical to use this procedure on a regular basis.

Statistic

World Health Organization, 2006.

  • Untreated gonococcal and chlamydial infections in women will result in pelvic inflammatory disease in up to 40% of cases. One in four of these will result in infertility.

  • Women who have had pelvic inflammatory disease are 6–10 times more likely to develop an ectopic (tubal) pregnancy than those who have not, and 40%–50% of ectopic pregnancies can be attributed to previous pelvic inflammatory disease

National Institute of Allergy and Infectious Diseases, National Institute of Health Fact Sheet, 1998.

    Each year in the United States, more than 1 million women experience an episode of acute PID, with the rate of infection highest among teenagers. More than 100,000 women become infertile each year as a result of PID, and a large proportion of the 70,000 ectopic (tubal) pregnancies occurring every year are due to the consequences of PID. In 1997 alone, an estimated $7 billion was spent on PID and its complications.

CDC STD Information, Pelvic Inflammatory Disease, 1999

  • Annually more than 150 women die from PID or its complications.

Signs and Symptoms

The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.

Pelvic inflammatory disease (PID) can result from the use of an intrauterine device (IUD). The onset of PID associated with IUD use is typically gradual and preceded by a foul smelling, heavy vaginal discharge characteristic of bacterial vaginosis. PID can also result from various sexually transmitted diseases. The onset of gonococcal PID has been more sudden than that of chlamydial PID in some but not all studies, and PID of either cause usually presents during the first half of the menstrual cycle.

Acute Pelvic Inflammatory Disease

  • Pain or tenderness in the lower abdomen
  • Vaginal discharge
  • Fever
Chronic Pelvic Inflammatory Disease

  • Mild recurrent pain in the lower back or abdomen
  • Pain during intercourse
  • Inability to become pregnant
  • Foul smelling, heavy vaginal discharge

Treatment Options

Conventional

Hospitalization should be considered in all cases of PID and is strongly recommended when: (1) the diagnosis is uncertain and surgical emergencies such as appendicitis and ectopic pregnancy cannot be excluded; (2) pelvic abscess is suspected; (3) severe illness or nausea and vomiting would make managing the condition on an outpatient basis unlikely; (4) the individual is pregnant or suspects that she is pregnant; (5) the patient is an adolescent (since the compliance of adolescents is less predictable than that of adults); (6) the patient has HIV infection; (7) the patient is assessed as unable to follow or tolerate an outpatient regimen; (8) the patient has failed to respond to outpatient therapy; or (9) clinical follow-up after 48 to 72 hours of antibiotic treatment cannot be arranged. (9)

Therapy should be started with a combination of antibiotics, since no single agent would cover all the possible invading microorganisms. Normally these antibiotics are given intravenously for the first 48 hours and then orally to complete a 14 day therapy. Adherence to the particular drug therapy that is recommended by the physician is critical to successful treatment.

Sexual partners of patients with PID should be examined for sexually transmitted diseases (STD's) and promptly treated with a regimen effective against gonococcal and chlamydial infections. Follow up with both patients should be done to insure compliance with the medication regimen.

Nutritional Suplementation


Antioxidant Nutrients

The use of antioxidant nutrients such as vitamins C, A, E, and the mineral selenium may be useful as lipid peroxidation has been found in individuals with PID.

Herbal Suplementation


Cat's Claw

In treating PID, herbal therapies are considered to be useful for assisting with the associated symptoms. For this reason it might be practical to use cat’s claw because of its immunostimulating, anti-inflammatory, and antioxidant properties. (10) , (11) , (12)


Bromelain

The use of bromelain may be indicated as a way to address inflammation associated with PID. The German Commission E approves the use of bromelain in surgical swelling, particularly of the nasal sinuses. (13) Bromelain is used clinically in conditions such as upper respiratory congestion, soft tissue inflammation and arthritis, dyspepsia, and dysmenorrhea, as well as a digestive aid. (14)

References

  1. Holmes KK. Pelvic Inflammatory Disease. In: Fauci AS, Braunwald E, Isselbacher KJ, et al. eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:812-817.
  2. View Abstract: Ory HW, and the Women’s Health Study. Ectopic pregnancy and intrauterine contraceptive devices: New perspectives. Obstet Gynecol. 1981;57:137.
  3. View Abstract: Westrom L. Effect of acute pelvic inflammatory disease on fertility. Am J Obstet Gynecol. 1975;121:707.
  4. View Abstract: Westrom L. Incidence, prevalence, and trends of acute pelvic inflammatory disease and its consequences in industrialized countries. Am J Obstet Gynecol. 1980;138:880.
  5. View Abstract: Westrom L. Incidence, prevalence, and trends of acute pelvic inflammatory disease and its consequences in industrialized countries. Am J Obstet Gynecol. 1980;138:880.
  6. View Abstract: Burnakis TG, Hildebrandt NB. Pelvic Inflammatory Disease: a review with emphasis on antimicrobial therapy. Rev Infect Dis. 1986;8:86.
  7. View Abstract: Westrom L. Incidence, prevalence, and trends of acute pelvic inflammatory disease and its consequences in industrialized countries. Am J Obstet Gynecol. 1980;138:880.
  8. View Abstract: Eschenbach DA. New concepts of obstetric and gynecologic infection. Arch Intern Med. 1982;142:2039.
  9. Holmes KK. Pelvic Inflammatory Disease. In: Fauci AS, Braunwald E, Isselbacher KJ, et al. eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:812-817.
  10. View Abstract: Aquino R, et al. Plant Metabolites. Structure and in Vitro Antiviral Activity of Quinovic Acid Glycosides from Uncaria tomentosa and Guettarda platypoda. J Nat Prod. 1989;52(4):679-85.
  11. View Abstract: Aquino R, et al. Plant Metabolites. New Compounds and Anti-inflammatorky Activity of Uncaria tomentosa. J Nat Prod. 1981;54(2):453-59.
  12. Wagner H, et al. The Alkaloids of Uncaria tomentosa and Their Phagocytosis-stimulating Action. Planta Med. 1995;5:419-23.
  13. Blumenthal M, et al, eds. Herbal Medicine: Expanded Commission E Monographs. Newton, MA: Integrative Medicine Communications; 2000:33-35.
  14. View Abstract: Monograph: Bromelain. Altern Med Rev. Aug1998;3(4):302-5.