PELVIC INFLAMMATORY DISEASE

Michelle  aged 33 came to see me complaining of infertility, meaning that she was unable to conceive within the last fourteen months, she was advised that the reason for this is damage to her tubes.
She was not aware of any illnesses that may have caused this, my immediate reaction was that she probably had very mild pelvic inflammatory disease at college, which often can be silent and can cause tubal damage.
Technically (PID) is a term used to express infection of the uterus , tubes and ovaries, which often results in long term damage of the tubes, adhesions and infertility. This causes chronic Dyspareunia, pelvic pain and backache.
I feel that the infections of the cervix, vagina and vulva should also be included as PID.

The main reason for PID in younger people is by sexually transmitted infections, the typical person having these problems is a young women having periods and sexually active.
The other causes of PID are infections during an abortion or miscarriage, intrauterine devices and blood born diseases, such as Tuberculosis which is relatively rare in the western world.

The infecting organisms, Chlamydia Trachomatis, Neisseria Gonorrhoea are sexually transmitted bacteria which can cause asymptomatic infection or very serious disease.
Other sexually transmitted disease are Herpes Virus, which causes changes in the cervix called cervical dysplasia and this if progressed can lead to cervical cancer, this does not cause an infection of the uterus, tubes or the ovaries or in other words the internal organs. Trichomonas  Vaginalis which is not a bacteria but is a protozoa. (A type of infecting organism) which is also sexually transmitted. It mainly affects the vagina causing smelly discharge and itching.

Other organisms that live happily in that region are likely to cause infection such as streptococcus Ecoli.

The diagnosis in Michelle's case was made by laparoscopy when on testing the tubes they were found to be blocked and convoluted. This can also be tested by a radiological test , but laparoscopy gives better information as regards adhesions in the pelvis. So obviously she must have had a silent episode of PID in her younger years. By the frequent nature of silent STD's amongst young women it was assumed that this was also an STD. A cervical swab was performed for Chlamydia and Gonorrhoea but as expected it was negative for both. Besides the swabs, laparoscopy and ultrasound often prior to laparoscopy and blood tests are also performed. The blood test which can give us an idea of an active infection is called CRP.

When you have mild symptoms of pelvic pain, altered menstrual function, pain on intercourse, please do not ignore them and do not run the risk of silent PID, as we have learnt in Michelle's case the long term consequences can be permanent.

Thanks to modern assisted reproductive technology, Michelle was helped to have a healthy baby.

When a women presents with pelvic pain, altered bleeding, there are many other conditions that have to be kept in mind. One of the most important is an Ectopic Pregnancy. The current pregnancy tests are extremely accurate, and if it is a positive result it's highly possible that the women has an Ectopic Pregnancy , this could be the result of a past or present PID.
Other diagnoses that should be remembered are appendicitis, septic abortion, haemorrhagic ruptured ovarian cyst, twisted ovary, degenerating fibroid and enteritis.

Clinical history, pelvic examination, blood test, pregnancy test, ultrasound, swab test, and finally laparoscopy will give us the diagnosis.
The treatment depends on the cause and in PID multiple antibiotic therapy is recommended as often we are unable to grow the infecting organism in PID.
It is very important to clear the PID as the long term consequences are serious and dangerous, as already mentioned it can cause infertility, chronic PID, chronic adhesions even affecting the liver, Ectopic Pregnancy, and even death in some situations.

PID is a serious disease and every attempt should be made to treat it early on very minor symptoms, such as vaginal discharge, pain and bleeding.
The most important thing is to have regular medical check ups if you are sexually active, and should you have a new sexual partner have him tested for STD's.
The second thing is do not take over the counter medicines for vaginal discharge or itch, without a proper diagnosis. All that itches is not thrush.
I have seen a women in her seventies who was treating herself for thrush and in fact it was vulval carcinoma.
Post menopausal women do not get thrush unless they are diabetic or taking excessive HRT.
Although women who are post menopausal, are not so prone to PID, but occasionally they get a collection of pus inside the uterus called pyometra, this needs treatment.

The moral of the story is do not consider vaginal discharge insignificant, have it seen to, and do not treat yourself.
We will discuss the superficial pelvic infections on my next post.