Pelvic Inflammatory Disease (PID)

What causes pelvic inflammatory disease?

Pelvic inflammatory disease (PID) is an infection of the uterus (womb) and fallopian tubes (and sometimes the ovaries too). The bacteria that cause the infection usually travel into the uterus from the vagina or cervix (neck of the uterus).

• A common cause of PID is from a sexually transmitted infection (the bacteria are passed on when you have sex). A bacterium called chlamydia is the most common cause. Gonorrhoea is another quite common cause of PID. A mixture of chlamydia plus gonorrhoea sometimes occurs. Sometimes the bacteria can be in the cervix for quite some time without causing symptoms before traveling into the uterus. This is why some women develop PID weeks or months after having sex with an infected person.
• Some cases of PID are not due to a sexually transmitted infection. The vagina normally contains various bacteria. These are normally harmless and are not passed on by sexual contact. However, these bacteria sometimes causes PID. This is more of a risk after having a baby, or after a procedure such as an insertion of an intrauterine device (IUD).

• Pain in the lower abdomen (pelvic area) is the most common symptom. It can range from mild to severe.
• Other symptoms that may also occur include:
  • Abnormal vaginal bleeding occurs in about 1 in 4 cases. This may be periods that are heavier than usual, or bleeding between periods, or bleeding after having sex.
  • Pain during sex.
  • Abnormal vaginal discharge.
  • Fever.
  • Low back pain.

Symptoms may develop quickly. You can become quite ill over a few days. Sometimes symptoms are mild and develop slowly. For example, you may just have a mild abdominal pain that may 'grumble on' for weeks. In some cases no symptoms develop and you do not know that you are infected. However, you are still at risk of complications even if you have no symptoms at first.

Who gets pelvic inflammatory disease?

About 1 in 50 sexually active women in the UK develop PID each year. It most commonly develops in women aged between 15 and 24. The risk of developing PID is higher if you have had:

• a recent change of sexual partner. The risk goes up with the number of changes of partner.
• a previous episode of PID.
• a recent termination of pregnancy (abortion).
• a recent operation to the uterus. For example, a dilation and curettage (D & C).
• an intra-uterine contraceptive device (IUD) inserted recently.

How is pelvic inflammatory disease diagnosed?

If PID is suspected then a swab (small sample of discharge) is usually taken from the cervix. This is to test for bacteria. A swab from the urethra (urine tube) and blood and urine tests may also be taken to look for infecting bacteria or the effects of infection.

However, even in women who have PID, the swabs and tests may not show any bacteria. Therefore, to confirm PID, a doctor may sometimes need to look inside your abdomen with a special 'telescope' (laparoscopy) which is done under anaesthetic.

PID may not be diagnosed for some time if symptoms are mild, or do not occur at first.

Complications do not develop in most cases if PID is diagnosed and treated early. Possible complications include one or more of the following.

• Difficulty becoming pregnant (infertility). PID can cause scarring or damage to the fallopian tubes. This can occur whether or not the PID caused symptoms.
• An increased risk of an ectopic pregnancy if you become pregnant. (This is a pregnancy that develops in a fallopian tube and can cause serious problems.) Again, this is due to damage to the fallopian tube by the infection. If you have had PID and become pregnant, you have about a 1 in 10 chance that the pregnancy will be ectopic.
• Chronic (persistent) pain develops in about 1 in 5 cases. This often includes pain during sex.
• The risk of developing some complications of pregnancy such as miscarriage, premature birth, and stillbirth are increased in pregnant women with untreated PID.
• Reiter's syndrome. This is an uncommon cause of arthritis and eye inflammation. It is an uncommon complication of PID. It is thought to be due to the immune system 'over-reacting' to pelvic infection in some cases.

You are less likely to develop complications if you begin treatment within 2-3 days of symptoms starting. This may be possible if symptoms develop quickly. However, some women with PID have mild symptoms, or no symptoms at all. The infection may progress for quite some time before it is diagnosed or treated.

The usual treatment is a course of antibiotics for at least two weeks. Two antibiotics are commonly prescribed. This is to cover the range of possible bacteria that can cause PID. It is important to take the full course of treatment.

Tell your doctor if you are (or may be) pregnant. This may affect the choice of antibiotic.

You should not have sex until both you and your sexual partner have finished treatment.

Yes. Also, any other sexual partner within the past six months should be tested for infection. (If you have not had sex within the last six months then your latest sexual partner, however long ago the relationship was, should be tested and treated.) A course of antibiotics is usually advised whether or not infection is found on testing. This is because:

• A significant proportion of PID is caused by chlamydia. It is often passed on during sex.
• Men often have no symptoms with chlamydia, but can still pass on the infection.
• The test for chlamydia is not 100% reliable. Treatment makes sure that any possible infection which may have been missed by the tests is cleared.
• If your sexual partner is infected and not treated, chlamydia may be passed back to you again after you are treated.

Wearing a condom during sex helps to protect you from sexually transmitted infections. The risk of infection increases with the number of changes of sexual partner.

About 1 in 5 women who have PID have a further episode. This is usually within two years. Reasons why this may occur include:

• If your sexual partner was not treated. You are then likely to get the infection back again.
• If you did not take the antibiotics properly, or for long enough. The infection may then not clear completely, and may flare up again later.
• If you change your sexual partner and do not practice 'safer sex'.
• Some women are more prone to infection once their uterus or fallopian tubes have been damaged by a previous episode of PID.

If you have ever had PID, then see a doctor as soon as you think that you may be pregnant. An early ultrasound scan is usually advised if you become pregnant. This checks that the pregnancy is in the uterus and not 'ectopic' in a fallopian tube.

Web resources
www.rcog.org.uk - Royal College of Obstetricians and Gynaecologists
Their website contains clinical guidelines and patient information about PID.

www.ssha.info - Society of Sexual Health Advisers
Information on sexually transmitted infections and related issues. Includes contact details of all the Genito-Urinary Medicine (GUM) clinics in the UK and Ireland.

www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/Chlamydia/fs/en
Information about chlamydia from the Department of Health. Includes information about the national screening programme to detect young people with chlamydia who do not have symptoms.

© EMIS and PIP 2006   Updated: June 2006   PRODIGY Validated