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Pelvic inflammatory disease

Introduction

Pelvic inflammatory disease (PID) is a bacterial infection of the female upper genital tract, including the womb, fallopian tubes and ovaries.

It’s a common disease and around 1 in 50 sexually active women in the UK are diagnosed with PID every year. Many more women with PID experience few or no symptoms.

PID mostly affects sexually active women between the ages of 15 and 24.

What are the symptoms of PID?

PID can be difficult to diagnose as the symptoms of PID are not always obvious. However, the warning signs can include:

  • pain around the pelvis or lower abdomen
  • discomfort or pain during sex 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

When to see your GP

It’s important to see your GP if you experience any of the above symptoms. Delaying treatment for PID or having repeated episodes of PID can increase your risk of infertility.

To diagnose PID, your GP may need to carry out several tests including a swab test, blood test or an ultrasound scan. In severe cases of PID where other conditions are suspected, you may need a laparoscopy.

You can also visit a sexual health clinic for a check-up.

Read more information about diagnosing PID.

What causes PID?

Most cases of PID are caused by an infection that has spread from the vagina or the neck of the womb (cervix) to the reproductive organs higher up.

Many different types of bacteria can cause PID, but most cases are the result of a sexually transmitted infection (STI) such as chlamydia or gonorrhoea.

This means that the most effective way of preventing PID is to protect yourself against STIs by using a barrier method of contraception such as a male or female condom, and to get regular sexual health check-ups.

Read more information about the causes of PID.

What happens?

When infection spreads upwards from the cervix (entrance to the womb), it causes one or more of the following:

  • inflammation and infection of the endometrium (womb lining), known as endometritis
  • inflammation and infection of the fallopian tubes, known as salpingitis
  • inflammation and infection of the tissue around the womb, known as parametritis
  • inflammation and infection of the ovaries, known as oophoritis
  • a pocket of infected fluid in the ovary and fallopian tube, known as an abscess
  • inflammation and infection of the peritoneum (lining of the inside of the abdomen), known as pelvic peritonitis

If you develop salpingitis, the lining of the fallopian tubes swells and the canals become even narrower. This means that fertilised eggs may not be able to move along them normally, increasing the risk of ectopic pregnancy (a pregnancy that starts outside of the womb) and infertility.

Read more information about the complications of PID.

Treating PID

If diagnosed at an early stage, PID can be treated quickly with a course of antibiotics which usually lasts for 14 days. It is important to complete the whole course, and to avoid having sexual intercourse during this time as it can interrupt the healing process.

However, further infection is common. After a first episode of PID, one woman in five has more episodes, mostly within two years.

Read more information about how PID is treated.

Fertility

An estimated one woman in five who have PID becomes infertile as a result. However, most women are able to get pregnant without problems after a single episode of PID

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Symptoms

The symptoms of pelvic inflammatory disease (PID) are fairly general, which means 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
  • pain during urination
  • bleeding between periods and after sex
  • unusual vaginal discharge, especially if it is yellow or green
  • fever and vomiting
  • pain in the rectum (back passage)

You may have PID without being aware of it. Sometimes there are no symptoms at all or symptoms may not be obvious. For example, you may only experience mild discomfort.

When to see your GP

It’s important to see your GP if you experience any of the above symptoms. Delaying treatment or having repeated episodes of PID can increase your risk of infertility.

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Causes

Pelvic inflammatory disease (PID) can be caused by an infection in the vagina. The bacteria can move up 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 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 (STIs) – chlamydia and gonorrhoea.

In the UK, the bacteria that cause chlamydia (Chlamydia trachomatis) are responsible for 50-65% of cases of PID. The bacteria that cause gonorrhoea (Neisseria gonorrhoeae) are responsible for 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 test or after the fitting of an intrauterine device (IUD).

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, these types 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.

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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.

Your doctor will examine you for tenderness in your pelvic region and an abnormal vaginal discharge.

They will usually take swabs from inside your vagina and cervix, which will be sent to a laboratory to identify the type of bacteria 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 may have a blood test or an ultrasound scan. Scans can show severe PID but will not pick 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 operation where two small cuts are made in the abdomen. A thin camera is inserted so that the doctor can look at your 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
  • you are unable to take oral antibiotics and need to be given them through a drip (intravenously)
  • you may need emergency surgery, for example for appendicitis
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Treatment

If it is 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.

Read more information about the complications of pelvic inflammatory disease (PID).

If you have mild or moderate PID, your GP or sexual health clinic will usually manage your treatment.

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, so a combination of antibiotics may initially be prescribed so that a variety of bacteria can be treated. It’s important to treat PID quickly to minimise the risk of infertility.

If your doctor is able to identify the bacteria, your antibiotics may be changed accordingly. Antibiotics that are commonly prescribed to treat PID include ofloxacin, metronidazole, ceftriaxone (brand name Rocephin) and doxycycline.

You will usually have to take the antibiotics for 14 days. It is very important to 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 abscesses (collections of infected fluid) 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 it is that scarring will occur. Prompt treatment is essential for minimising the risk of damage to the fallopian tubes and other reproductive organs.

Studies suggest that delaying treatment by even 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 infection.

This is only 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 in-vitro fertilisation (IVF).

Avoiding sex and contacting sexual partners

Avoid having sexual intercourse until you have completed your treatment. This is because 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 previous 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

There are several complications associated with pelvic inflammatory disease (PID), including repeated episodes of PID, an abscess forming and an increased risk of an ectopic pregnancy or infertility.

Recurrent pelvic inflammatory disease

Women often experience repeated episodes of PID, this is known as recurrent pelvic inflammatory disease. The more often a woman gets PID, the more likely she is to get it in the future.

The condition can return if the initial infection is not entirely cured or because a sexual partner has not been tested and treated.

If an initial episode 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 at 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 abscesses 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 that occurs outside the womb.

More than 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 can be life threatening.

Infertility

It is estimated that one woman in five women with PID becomes infertile as a result. 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 impossible for the egg to travel down into the womb. Delaying treatment for PID can increase your chances of becoming infertile.

Read more information about infertility.

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

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Prevention

The most effective way to prevent pelvic inflammatory disease (PID) is to protect yourself from sexually transmitted infections (STIs).

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 (STI).

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 been 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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