Pelvic Inflammatory Disease and Infertility

Pelvic inflammatory disease is a polymicrobial infection caused by organisms found in the vagina like streptococcus and several different types of bacteria. Which can cause Pelvic inflammatory disease along with this same type of bacteria also cause sexually transmitted infections (STIs) gonorrhea and chlamydia. In 85% of cases of PID, the infection is caused by sexually transmitted bacteria [2]. This bacteria first enter the vagina and causes an infection. As time passes, this infection can move into the pelvic organs and make the condition very serious. Women develop the pelvic inflammatory disease when Sexually transmitted disease-causing bacteria enter the vagina then it passes through the cervix and enters into the uterus; infecting the whole pelvic area including ovaries and fallopian tubes. The diagnosis of PID is primarily clinical and should be suspected in female patients with lower abdominal or pelvic pain and genital tract tenderness. The diagnosis may be delayed when the patient has no signs and symptoms [3]. Most importantly, it is associated with fallopian tube inflammation and infection, which can lead to infertility, ectopic pregnancy, and chronic pelvic pain in the future [4].

Patients with acute pelvic inflammatory disease present with a wide range of non-specific clinical symptoms. symptoms usually appear at the time and immediately after the menstruation. The symptoms of pelvic inflammatory disease vary in different women. If you have severe symptoms, consult your doctor immediately. The infection can spread to your blood or other parts of your body; this can result in life-threatening. Sometimes these symptoms resemble urinary tract infection (UTI), ovarian cyst, gastroenteritis, irritable bowel syndrome, endometriosis, appendicitis.

Signs & Symptoms doctors should consider as potential symptoms associated with the disease, particularly in women at risk of sexually transmitted infection may include -

• Pain (lower abdomen)- bilateral lower abdominal pain which is dull. The onset of pain is more rapid.
• Pain during sexual intercourse
• Fever and chills-temperature is elevated beyond 38.3°C
• Vaginal discharge with odor- abnormal vaginal discharge which becomes purulent and copious (more in quantity) if the condition becomes worse. It may be yellow or green in color.
• Pain and burning sensation during urination
• Irregular menstrual cycle and spotting- bleeding between the periods [5]
• Vomiting
• Fatigue
• Sometimes the pain in the upper right abdomen

Time to consult your doctor

You should take immediate medical attention if you experience any of the following:

• An Unusual sore in your private area.
• Severe pain in your lower tummy.
• Nausea and vomiting sensation
• Foul vaginal secretion
• Fever with a temperature of more than 101 Fahrenheit or 38.3 C.

If you have any of the symptoms of PID like mentioned above that are mild, still you should meet your doctor, as these symptoms may also be related to STDs. If you notice these symptoms, stop having sex and consult a doctor as early treatment of STD can help prevent serious and long-term complications caused by PID.

It is mostly a disease caused by unprotected sex and bacteria named chlamydia trikomitis. During sexual intercourse, these bacteria move from the vagina and enter into the pelvic region which causes PID.

Causes of Pelvic Inflammatory Disease (PID) may include-

• Unprotected sexual contact with someone who has an STD is the most common cause of PID
• Medical processes like abortion, miscarriage, childbirth, insertion of contraceptive devices can also lead to bacterial infection and become the cause of PID
• Sex with a number of people or number of partner
• Sex before the age of 20
• History of STD (sexually transmitted disease) also increases the chances of Pelvic Inflammatory Disease.

Some women get PID without having sexual intercourse; normal bacteria present in the vagina can cause PID sometimes.

Various factors might increase your risk of pelvic inflammatory disease including-

• Age of sexually active women more than 25 year
• Having sex with multiple partners
• Sex without condom
• Insertion of IUD (intrauterine device)
• History of pelvic inflammatory disease or a sexually transmitted infection that is not treated properly.
• Douching (washing or cleaning out the vagina with water or other fluid mixtures) regularly, it causes pushing up of the harmful bacteria that are linked to causing infections from the vagina into upper reproductive organs and results in PID symptoms. It is said that your signs of PID are hidden by douching.

Bacterial vaginosis BV is a condition seen in women who douche and is caused due to changes in the number of certain types of bacteria in your vagina [6]. It is very common and easily treatable but when left treated, it raises your risk of STIs and may end up causing PID as well.

One study states that women who are having a pelvic inflammatory disease or a history of PID, 1 out of 8 women have difficulties getting pregnant also it can lead to serious and long-term problems. If PID is diagnosed and treated on time, the complications of PID can be prevented. Some of the complications of PID include-

Ectopic pregnancy: when PID is untreated it forms scar tissue in the fallopian tube that leads to the blocked fallopian tube. PID is a major cause of ectopic pregnancy. Due to this, there will be a difficulty for the egg to reach the uterus. Therefore, eggs get implanted in the fallopian tube and ectopic pregnancy happens. It becomes life-threatening and requires immediate medical attention.

Infertility: PID damages reproductive organs in women and leads to infertility in women. 10% of women suffer infertility due to pelvic inflammatory disease. PID condition prevents women from getting pregnant. Hence, it causes infertility. If women are suffering from PID at any point in their life, they will have to undergo immediate treatment to restore their infertility.

Tubo ovarian abscess: sometimes pelvic inflammatory disease may cause an abscess in the female reproductive system which affects the fallopian tube and ovaries of women. An abscess is filled with pus. This type of condition required immediate treatment because if an abscess is left untreated, you could develop a life-threatening infection.

Long-term abdominal pain or pelvic pain: You may experience pain in your pelvis due to PID that can last from months to years. Scars that are formed in fallopian tubes and other organs cause pain when stretched while you have sexual intercourse and during ovulation time.

A study done to improve awareness of PID and its complications like infertility, chronic pelvic pain, ectopic pregnancy shows that the complications are preventable by doing screening tests for asymptomatic patients for their STIs and also by doing a prompt treatment of individuals with STIs and PID.

There are multiple tests for diagnosing pelvic inflammatory disease. PID diagnosis is based on findings of lower genital tract inflammation and an associated tenderness of your pelvic organs [7]. But in most patients' medical history, pelvic exams and vaginal cultures are needed to make the diagnosis of pelvic inflammatory disease. Diagnosis for pelvic inflammatory disease take place -

• By noticing symptoms and taking a medical and sexual history of the patient
• By Pelvic Examination: To check tenderness and swelling.unusual discharge from your vagina
• Culture Test: To identify pathogens that cause PID infection
• Urine and Blood Test
• Ultrasound-Image of the pelvic area by using sound waves

When the diagnosis is unclear, to know the exact cause of PID. Your doctor may recommend -

• Laparoscopy: laparoscopy procedure can give a clear view of the pelvic organ of women. This procedure is done with the help of a laparoscope.
• Culdocentesis: In this procedure, a needle is inserted behind the vagina in the pouch of Douglas and fluid is removed through the needle to see any signs of bleeding and infection.
• Endometrial Biopsy: In Endometrial biopsy, procedure tissue is removed from the lining of the uterus for evaluation and testing for any sign of infection and inflammation.
• CT or MRI scan: These are done to identify any abscess or swelling of fallopian tubes.

The tests that help in PID diagnosis are as follows:

Laboratory Tests for PID

The tests that your doctor may suggest to know the cause of PID and to rule out other causes of your pelvic pain are [8]:

• Chlamydia trachomatis test: This test helps to know the chlamydia infection as the main cause of your PID.
• Neisseria gonorrhea test: If your PID is due to infection from Neisseria, then it is diagnosed through this test.
• Wet prep: Cervical or vagina discharge is collected and placed on a sample slide to be examined under a microscope. It is done to know the number of white blood cells WBCs that are present in the discharge. In the case of PID, the WBC count is increased.
• Cervical culture: The doctor makes use of cotton swabs to collect fluid samples from your cervix and send them for testing the presence of organisms like gonorrhea and chlamydia.
• Urinalysis and culture of urine: Urinary tract infection can be traced out by urine culture.

Doctors may also order tests that are not specifically related to PID in order to know any associated inflammation and immune response. They may be as follows:

• CRP or C-reactive protein test: This is said to be a general or nonspecific marker of your body’s inflammation. In the case of PID, you have an increased CRP level. C-reactive protein is produced by your liver, in order to fight any infection or inflammation that occurs in your body.
• ESR or Erythrocyte sedimentation rate: This is another non-specific indicator of your inflammation and your doctor orders it when CRP is not available. ESR helps to know the inflammation that is triggered by an infection or some autoimmune disease.
• CBC or complete blood count: If there is an infection in your body, then the number of white blood cells that are released to fight infection is increased. CBC, a test done to measure your total number of white cells in your blood, is ordered if your doctor wants to know any presence of infection or any immune system disorder.
• Pregnancy test: To know if the woman is pregnant or to identify ectopic pregnancy, a pregnancy test is performed.

Treatment is given by your doctor based on Your age, Your overall medical and health history. Your sickness severity, Your ability to respond to certain medications, and procedures or therapies. At an early stage, it can be treated easily and effectively with antibiotics medication. It can cause more serious long-term complications if it is left untreated. Treatment that is usually recommended is-

Medication - after seeing your diagnosis, the doctor may prescribe you oral antibiotic medicine. Antibiotic coverage for vaginal anaerobic bacteria should be considered when treating severe Pelvic Inflammatory Disease (PID). [9]

If you have pain in the abdominal area you can take painkillers like paracetamol or ibuprofen while treated with antibiotics. Make sure that you are taking antibiotics regularly in prescribed doses. Oral antibiotics for PID are beneficial in reducing signs and symptoms associated with PID, and clinical and microbiological cure rates of 88% to 100% have been noticed with oral antibiotic treatment [10].

Centers for Disease Control and Prevention CDC, recommends the following as first-line treatment:

For outpatients with PID [11]:

Doxycycline 100mg orally, taken twice a day for 2 weeks plus ceftriaxone 250mg intramuscularly IM as one dose or Cefoxitin 2g IM with Probenecid 1g orally for one dose.

For inpatients with PID:

Cefotetan ( 2g Intravenously IV every 12 hours)plus doxycycline (100mg orally every 12 hours)or Cefoxitin (2g IV every 6 hours) plus doxycycline (100mg taken by mouth every 12 hours) or Clindamycin (900mg IV every 8 hours) plus gentamicin (3 to 5 mg/kg IV daily once).

Hospitalization - Hospitalization is recommended when antibiotic treatment is not effective or your symptoms get severe (nausea, vomiting, and a fever)

Treatment of your sexual partner - Tell your partner about infection and get tested and treated if needed

Temporarily stop having sex - Avoid sex until symptoms get completely resolved from PID and treatment gets completed.

Other treatment - take bed rest if you are suffering from severe pain, apply a hot compress to the lower abdomen in pain.

Surgery - After taking all possible treatments like antibiotics and other treatments. If your body doesn't respond to that treatment then you surely need surgery. If there is a danger of rupturing your abscess, you may need surgery to drain it. If your doctor thinks that PID has damaged your pelvic organs severely, then you may need to undergo a hysterectomy. If the infection is in the urinary tract then hysterectomy does not help. It is rarely needed in cases of persistent and exhausting PID.

You cannot prevent PID directly but you can prevent sexually transmitted infection. Experts suggest that the only way to avoid STIs from occurring is not to have either vaginal or oral or anal sexual intercourse. According to a study, prevention of PID falls into 2 categories: Preventing the first episode of PID and preventing the recurrence of the disease. Also from a study, it was proved that there is a reduced incidence of pelvic inflammatory disease when women have increased risk of developing cervical chlamydial infection were strategically identified, tested, and treated [12].

These steps work best when used together. In a sexually active person, the risk of getting STIs can be significantly lowered by following these steps: [13]

• Using condoms: Your chance of getting in contact with infection-causing bacteria is greatly reduced with the use of condoms. Though the condom will not give 100% prevention of STIs, it can surely provide you some protection against STIs.
• Get yourself tested: If you think you are at risk of developing PID, consult a doctor immediately, and get tested. Regular screening and early treatment of your STIs helps you to have a better chance of avoiding PID.
• Make sure of testing your partner: If you have been diagnosed with PID or have chances of developing PID, immediately you are advised to get your partner to understand the consequences of PID. Make your partner undergo tests and treatment that helps in possible spread and recurrence of PID.
• Limit sexual partners: You can reduce your risk of getting exposed to STIs by having limits on your sexual partners.
• Stick to a single partner (monogamous): Having sexual relationships with only one partner is monogamy. This helps a lot in preventing the risk of PID.
• Limiting alcohol or drugs: Too much intake of alcohol or consuming drugs provokes risky behavior and increases the risk of getting exposed to a person having STIs.
• Don’t Douche: Regular and prolonged douching washes away the normal bacteria from your vagina that helps to fight infections. It also allows the bacteria to travel up reaching other reproductive organs where they can spread infection.

It is more difficult for a woman with PID to get pregnant. About 1 in 10 women who have PID becomes infertile. The bacterium that enters through the vagina spreads to fallopian tubes resulting in inflammation and scar formation of tubes. This scar tissue thus formed in fallopian tubes makes it much harder for the sperm to fertilize the egg. Even mild scar tissue can give troubled pregnancy. Many women with PID history can still conceive with the help of fertility treatments like IVF. Women having one episode of PID will have a 15% risk of infertility, with two episodes the risk is 35% and those having three episodes will have an infertility risk of 75%.

IVF is an effective treatment for your difficult conditions of infertility as it bypasses some of the common causes of infertility like damaged tubes or poor sperm quality. In-vitro fertilization means your egg is fertilized with your partner’s sperm in a special lab dish outside your body under highly controlled hygienic conditions. Fertility drugs are given to you at the beginning of IVF to improve your egg production and then your doctor will remove matured eggs from your ovaries by inserting a thin needle through the vagina. These eggs are now allowed to mix up with sperm cells to form embryos and they are allowed to grow for 3 to 5 days. The embryo is then placed back into the uterus through the vagina using a small catheter to get implanted onto the uterine walls.

A study suggests that the high rate of infertility that occurs post-infection was found due to tubal damage that occurred before and during the first episode of PID [14]. For effective prevention of permanent damage to fallopian tubes, prevention of recurrent PID, and better knowledge of tubal damage pathophysiology is needed.

Pelvic Inflammatory Disease (PID) in Men

In men, the bacteria that cause PID do not show any symptoms like the presence of abnormal discharge or painful urination. So, they pass these bacteria onto their partners unknowingly while having vaginal sex. In such cases, screening tests for STIs can help to stop spreading to female partners. If a man is said to have an STI, which is the main cause of PID, then he can prevent spreading it to his partner by using condoms, getting antibiotic treatment, and avoiding sex until STI gets clearly resolved.

There are few things like below that you can do to handle the pain due to PID before your lab reports are received and your antibiotics start to work.

• You can do mild-to-hot baths and apply a heating pad on the lower belly that helps to ease your pain and also bring disease-fighting blood cells to your pelvic area.
• You can also place a cotton cloth soaked in Castor oil on your lower abdomen, secure it with a plastic band and then place a heating pad or a bottle filled with hot water. This helps to give a good heating effect on your pelvis and gives better pain relief.
• Ginger root taken in tea helps to compress your pain. A poultice ( a soft heated herbal mass that is spread on a cloth and applied over the skin to increase blood flow, relax tensed muscles and soothes inflamed tissues by removing toxins from an infected area) made out of taro or Arbi or Colocasia esculenta root, also help to lower your pain by loosening the area and by dissolving adhesions that are already formed.
• You are strictly advised not to use tampons or to douche, as these activities may cause forcing up of the harmful microbes into the uterus.
• Do not keep using your douche bag repeatedly as it may be the house of infectious microbes.

PID if neglected can lead to serious complications. So, you should only use complementary therapy which is a combination of a healthy nutritious diet and supplements, in association with your prescribed PID medications. You should also keep informing your doctor if using any of the supplements and therapies.

Nutritional Care That Helps To Fight Inflammation

You can improve your immunity to fight infections by taking a diet as follows:

• Include calcium-rich foods like beans, almonds, and dark green leafy vegetables like spinach.
• Include antioxidant-rich foods in your diet like tomatoes, cherries, and bell peppers.
• Try to eliminate food allergens that include dairy, wheat (gluten), corn, soy, any food preservatives, or additives.
• Reduce refined foods like sugar, pasta, and white bread.
• Cook your food with organic healthy oils like olive oil and coconut oil.
• Avoid eating fries, cookies, onion rings, donuts, processed foods, and other commercially baked foods, as they contain trans fatty acids.
• Avoid alcohol, coffee, and tobacco.
• Make a habit of drinking 6 to 8 glasses of water every day.

Supplements That Can Help to Improve Nutritional Deficiencies

The deficiency of essential nutrients in your body can be replaced by taking supplements as mentioned below.

• Daily multivitamin: Take antioxidant vitamins like A, C, E, and B-complex capsules. Add trace minerals like calcium, magnesium, zinc, and selenium.
• Omega-3 fatty acids: Taking 1 or 2 capsules or 1 tbsp. of oil, 1 to 2 times a day help to fight inflammation.
• Probiotic: good gastrointestinal and immunity is maintained by taking enough probiotics containing Lactobacillus acidophilus every day. If you are on immunosuppressive medications, speak to a doctor before taking probiotics.
• Grapefruit seed extract: For improving your antibacterial or antifungal activity, you can take a 100mg capsule or 5 to 10 drops of grapefruit seed extract 3 times a day, after speaking to your doctor.

PID is a common and highly contagious infection of upper female reproductive parts that includes the uterus, ovaries, and fallopian tubes of a sexually active woman who is younger than 25 years. It is not an easily notifiable disease. It remains a big challenge for a doctor to detect and manage PID patients. For this proper follow up with your doctor is essential.