Pelvic inflammatory disease (PID), an upper genital tract infection, occurs when microorganisms ascend from the vagina (vaginitis) or cervix (cervicitis) to the normally sterile uterus (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), and peritoneum (peritonitis). Infections may result from sexually transmitted diseases or from invasive surgical procedures. PID can be acute, silent, atypical, or chronic. One million women are diagnosed with PID annually in the U.S., with a peak incidence in the 15-to-24 age group.

The most common offending organisms are Neisseria gonorrhoeae and Chlamydia trachomatis, but a variety of anaerobic organisms (e.g., Bacteroides fragilis, Peptostreptococcus, Actinomyces, and Peptococcus spp.), facultative organisms (e.g., Gardnerella vaginalis, Streptococcus spp., Escherichia coli, and Haemophilus influenzae), and Mycoplasma hominis may play etiologic roles.

• Previous history of PID
• Heterosexual sexual activity (e.g., frequent sexual encounters, many partners)
• History of sexually transmitted disease
• Young age (15 to 25 years of age), particularly early age at first intercourse
• Uterine instrumentation (e.g., intrauterine device [IUD]) and invasive uterine procedures (e.g., dilation and curettage [D & C])
• Oral contraceptives increase the risk of PID associated with C. trachomatis, but decrease the risk of PID related to other organisms
• Menstruation—bacterostatic properties of cervical mucus are minimal at time of menses

Some women may be asymptomatic or have minimal or atypical symptoms that do not suggest PID. None of the signs and symptoms are pathognomonic for PID.

• Fever (> 38.3 C) and chills
• Bilateral lower abdominal pain and tenderness
• Cervical motion and adnexal tenderness
• Purulent cervical discharge (> 10 polymornuclear leukocytes/hpf)
• Leukocytosis (> 10,000/mm3)
• Elevated sedimentation rate (> 15 mm/hr) or C-reactive protein
• Dysuria (urethritis)
• Abnormal menstrual bleeding
• Anorexia, nausea, and vomiting
• Proctitis (anorectal pain, discharge, or bleeding)
• Perihepatitis (Fitz-Hugh-Curtis syndrome) and periappendicitis

• Acute appendicitis
• Endometriosis
• Ectopic pregnancy
• Pelvic adhesions
• Mesenteric lymphadenitis
• Corpus luteum hemorrhage
• Ovarian cysts and tumors
• Inflammatory bowel disease
• Interstitial cystitis

Most signs and symptoms are nonspecific and often mild; thus, physicians should take a thorough sexual history and maintain a high index of suspicion with high-risk patients so as not to miss PID, the sequelae of which can be devastating. Rapid diagnosis and effective treatment of lower urinary tract infections and routine screening for chlamydial and gonococcal infections of high-risk individuals are essential to prevent PID.

• Complete blood count to detect leukocytosis
• Urinalysis
• Cervical Gram's stain to detect intracellular gram-negative diplococci
• Erythrocyte sedimentation rate elevated in 75% of PID cases
• Cervical cultures to detect N. gonorrhoeae and C. trachomatis
• Fluorescein-conjugated monoclonal antibody test to diagnose chlamydial infection
• Enzyme immunoassay test to diagnose chlamydial infection

• Ultrasonography to diagnose and monitor tubo-ovarian abscess (TOA)
• Computed tomography scan to diagnose TOA

• Endometrial biopsy to diagnose subclinical endometritis
• Culdocentesis to detect elevated WBC count in cul-de-sac fluid
• Hysterosalpingography to determine tubal patency
• Laparoscopy to diagnose peritubal or periovarian disease (salpingitis) and to exclude diseases considered in the differential diagnosis

Some health care professionals advocate hospitalization for all PID patients; others recommend hospitalization only if other surgical emergencies (e.g., ectopic pregnancy, appendicitis) cannot be ruled out when the diagnosis is uncertain; the PID is severe; an abscess is present; compliance is an issue; the patient is prepubertal, pregnant, has AIDS, or has not responded to treatment; or follow-up within 72 hours cannot be arranged. Outpatient therapy consists of bed rest, pelvic rest, analgesics, and antibiotics.

The Centers for Disease Control recommends the multiple drug regimens listed below. Single-drug therapy has a 15% to 20% failure rate.

Outpatient:

• Cefoxitin, 2 g intramuscularly, plus probenecid 1 g orally (or ceftriaxone, 250 mg intramuscularly or equivalent cephalosporin), plus doxycycline, 100 mg orally bid for 14 days (or erythromycin, 500 mg orally qid for 14 days or tetracycline, 500 mg orally qid for 14 days)
• Ofloxacin, 400 mg orally bid for 14 days, plus clindamycin, 450 mg orally qid (or metronidazole, 500 mg orally bid for 14 days) [if not pregnant]

Inpatient:

• Cefoxitin, 2 g intravenously every 6 hours (or cefotetan, 2 g intravenously every 12 hours), plus doxycycline, 100 mg orally or intravenously every 12 hours (if not pregnant); doxycycline, 100 mg orally bid for 14 days after the first 48 hours
• Clindamycin, 900 mg intravenously every 8 hours, plus gentamicin, 2 mg/kg intravenously or an intramuscular loading dose followed by 1.5 mg/kg every 8 hours, with doxycycline, 100 mg orally bid for 14 days after the first 48 hours (or clindamycin, 450 mg orally qid for 14 days)

Surgery is reserved for the treatment of TOA that does not respond to antibiotics or that has ruptured.

• Laparoscopy to drain a TOA to preserve reproductive function
• Hysterectomy and salpingo-oophorectomy to treat bilateral TOA
• Unilateral adnexectomy to treat unilateral TOA

PID requires aggressive treatment to decrease risk of complications (e.g., infertility, sepsis). Nutrients and herbs may provide immune support and enhance overall health, and may be useful as adjunct treatment to decrease the risk of recurrence.

• Avoid sugars, refined foods, and saturated fats (e.g., animal products, especially dairy) which may compromise immune function and increase inflammation.
• Include whole foods such as fresh vegetables, whole grains, and essential fatty acids (i.e., nuts, seeds, and cold-water fish).
• Vitamin C (1,000 mg tid to qid), zinc (30 mg/day), selenium (200 mcg/day), vitamin E (400 IU/day), B-complex (50 to 100 mg, especially folic acid 800 mcg/day), and vitamin A (25,000 IU once to twice daily) or beta carotene (50,000 IU once to twice daily) to support immune function
• Bromelain (500 mg tid between meals) is a proteolytic enzyme that potentiates the action of antibiotics.
• Anti-inflammatory oils (e.g., flax, borage, evening primrose) 1,500 mg bid to tid
• Acidophilus to support immune function, decrease risk of yeast infection secondary to antibiotic therapy, and re-establish normal vaginal flora; take one capsule with meals, or one capsule twice daily between meals

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes).

• For acute infection, combine half parts of yarrow (Achillea millefolium), pasque flower (Pulsatilla pratensis), marigold (Calendula officinalis), and pokeroot (Phytolacca americana) with one part each of coneflower (Echinacea purpurea) and goldenseal root (Hydrastis canadensis). Take 30 to 60 drops tincture every two to four hours. Use caution with pokeroot.
• For chronic or latent infection, combine equal parts of coneflower, goldenseal, licorice root (Glycyrrhiza glabra), myrrh gum (Commiphora molmol), wild indigo (Baptisia tinctoria), and red root (Ceonothus americanus). Take 30 drops tincture bid to tid.
• Turmeric (Curcuma longa), 500 mg tid to enhance anti-inflammatory effects of bromelain

Homeopathic remedies may be useful in providing symptomatic relief and addressing chronic conditions. An experienced homeopath would consider the individual's constitution.

A castor oil pack applied externally to the abdomen reduces inflammation and can provide symptomatic relief. Saturate a cloth with castor oil and apply directly to the skin, placing a heat source (e.g., water bottle) on top. Leave in place for 30 minutes or more. For best results, use castor oil packs for three to four consecutive days per week. Packs may be used daily.

May aid in decreasing pain, reducing inflammation, and enhancing immune function, especially in chronic infections.

Physicians must reexamine patients after 48 to 72 hours of treatment to be sure the regimen is effective. If there is no clinical improvement, an alternative diagnosis or different antimicrobial therapy must be considered. All recent sexual partners (and their partners) must be contacted, examined, and treated to reduce the risk of re-infection.

• Risk reduction education and counseling by health care professionals
• Community health and promotion, using school education programs and mass media
• Barrier methods of birth control (e.g., condoms, diaphragms, vaginal spermicides) reduce the risk of PID

• Tubo-ovarian abscess
• Fallopian tube obstruction, resulting in ectopic pregnancy or infertility
• Chronic pelvic pain, from adhesions or persistent infection
• Sexual dysfunction

Of the one million cases of PID diagnosed each year, 15% fail the initial treatment regimen, 25% experience a recurrence, 20% experience chronic pelvic pain from complications, and infertility results in 12% to 15% after one episode, 25% to 35% after two episodes, and 50% to 75% after three or more episodes. A single episode of PID increases a woman's chance of an ectopic pregnancy seven-fold. Of all hysterectomies performed in the U.S. annually, 25% result from PID. Gonococcal PID has a better prognosis than chlamydial PID because patients seek medical attention earlier due to acute symptoms.

Although pregnancy complicated by PID is rare, the infection can be severe, resulting in high morbidity and high rates of spontaneous abortion and requiring aggressive antimicrobial therapy. Pregnant women should not use tetracyclines, erythromycin estolate, or quinolones (e.g., azithromycin).

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