Pelvic inflammatory disease, a critical problem
Occurence or recurrence of pelvic inflammatory disease or PID has been linked to STIs such as C. trachomatis or Neisseria gonorrhoeae. Patient education and simplified guidelines are needed to develop accurate diagnosis. In order for changes to take place, more research must be done to understand the complex nature of the disease and the most effective and cost effective method of treatment.
This paper delves into the risk factors, diagnosis processes, treatment, relevant psychological issues, public health implications, patient and family education, and appropriate referral to specialty by reviewing literature pertinent to PID. The results of the literature review show very little in the past was done in regards to researching symptoms of PID and treatment efficacy. New research shows lower abdominal pain as a main indicator of PID as well as C. trachomatis or Neisseria gonorrhoeae. The data also elaborates on the risks of infertility associated with PID.
The costs of treating infertility are high. The costs of treating of ectopic pregnancy, another risk of developing PID, is also high. Earlier detection, most importantly, preventative measures are needed to keep healthcare costs down and help women from developing the disease. Infertility is not only a costly problem, but one that affects women on a psychosocial level.
Pelvic inflammatory disease or PID, remains to this day, a mystery to the average medical professional. “PID affects around 10% of the reproductive-age female population each year.” (Landers & Sweet, 2013, p. 12) The mystery lies within attaining definitive diagnostic criteria and how to tell who has it and when a PID could form. One of the reasons why PID is so hard to diagnose, let alone determine within a set group, is due to the lack of laboratory test validation available that other infectious phenomena have.
Instead, providers must rely on their own clinical judgement to prevent the worst of the disease. Normally a regimen of various antibiotics prove successful in both inpatient and outpatient treatments; but, many patients tend to have complications such as tubo-ovarian abscess/tubal occlusion and may result in ectopic pregnancy and/or infertility. Women who experience PID must not only deal with the personal costs of this disease, but also the financial. PID treatment can turn costly and lead to high medical bills for both the patient and the hospital/clinic.
“PID is the clinical syndrome associated with upper genital tract inflammation caused by the spread of micro-organisms from the lower to the upper genital tract. PID can be caused by genital mycoplasmas, endogenous vaginal flora (anaerobic and aerobic bacteria), aerobic streptococci, Mycobacterium tuberculosis, and sexually transmitted infections (STI) such as C. trachomatis or Neisseria gonorrhoeae.” (Simms & Stephenson, 2000, p. xx-xx) Risk factors play an important role in determining who will most likely develop Pelvic inflammatory disease (PID). PID is most frequently caused by sexually transmitted infection (STI). “PID occurs because of migration of pathogens (most commonly chlamydia and gonorrhea) to the upper female genital tract, provoking tubal inflammation and subsequent tissue damage.” (Smith, Cook, & Roberts, 2007, p. xx-xx) To detect PID, and prevent further complications, women should undergo routine STI screening in order to rule out any STI’s being in the system. As Smith, Cook, & Roberts state in their paper, the Centers for Disease Control and Prevention (CDC) recommend annual screening for sexually active women aged 20-25 and adolescent women to aid in early diagnosis of PID. Although some recommend adolescent women and women under 25 go as much as every six months for STI screening especially routine gonorrhea screenings. The U.S. Preventive Services Task Force adds that previously infected women should get tested every 6- to 12-months due to high rates of reinfection
Liu et al. wrote about the very little research performed in improving practitioner and patient adherence to PID diagnosis and management guidelines. Of the three studies they identified, the need for further studies, particularly in primary care settings, should be performed. It is here where they found diagnosis and management of PID to be suboptimal, and where further research should be conducted. They advised that in order for diagnosis and treatment to improve, patient and practitioner must follow certain guidelines such as: “abbreviated practitioner clinical management guidelines, provision of the full course of antibiotic treatment to the patient at presentation, simplified antibiotic regimens, and written instructions for patients.” (Liu et al., 2012, p. xx-xx)
Blake, Fletcher, Joshi, & Emans wrote in their paper, that “most patients given a clinical diagnosis of PID in an adolescent medical setting reported lower abdominal pain in the medical history and that all patients diagnosed with PID reported either lower abdominal pain or dyspareunia.” These two symptoms may be seen as indicators of PID. When there is no presence of these symptoms, a low risk of PID may be noted. Of the many studies evaluating diagnostic indicators, only a few were performed in primary care settings, where most were done in hospital settings. “Many have used the symptom “lower abdominal pain” as a required inclusion criterion, preventing an analysis of the sensitivity and specificity of its presence.” (Blake, Fletcher, Joshi, & Emans, 2003, p. xx-xx) Blake et al. noted, most studies identified in their review used abdominal pain as a required inclusion criterion. Labeling it as a required inclusion criterion kept analysis of its sensitivity low and from being a diagnostic indicator.
Blake et al. further note that two studies used abdominal pain as a diagnostic indicator of PID. “In one study, 112 women undergoing diagnostic laparoscopy for infertility were interviewed prior to the laparoscopic procedure. Eighty percent of the women noted to have laparoscopic findings consistent with a previous episode of PID reported a past history of lower abdominal pain compared with 42% of those with no findings consistent with previous PID. In the other study 72 of 90 patients (82%) diagnosed with a lower genital tract infection due to chlamydia or gonorrhea and who had an endometrial biopsy consistent with endometritis reported abdominal pain as compared with 36 of 60 patients ( 60%) with lower genital tract infection but no endometritis.” (Blake, Fletcher, Joshi, & Emans, 2003, p. xx-xx)
Mirblook, Asgharnia, Forghanparast, & Soltani performed a study with an aim to compare two oral treatments: Ofloxacin and Metronidazole, with Azithromycin and Metronidazole in outpatients with PID. The study was administered through Randomized Clinical Trial in Al-zahra Women’s Hospital of Rasht. The number of women selected and who participated in the study were two hundred. Eligibility was based on the following criteria. Women with the three of the five following symptoms were considered: lower abdominal pain, vaginal discharge, adnexal tenderness, cervical motion tenderness and cervicitis. “Group A was treated with Ofloxacin (400 mg) with Metronidazole (500 mg) and Group B. was treated with a single dose of oral Azithromycin (1gr) with Metronidazole (500 mg) for 10 days.” (Mirblook, Asgharnia, Forghanparast, & Soltani, 2011, p. xx-xx) The regimens were compared with regards to efficacy and side effects. Patient check up began after two weeks passed from initial treatment.
The study lasted for six months with only 4 patients taken off treatment due to adverse reactions. After the six months, the study found that post-treatment cure rates for groups A and B. were 90.3% for group A and 93.75% for group B. Although there was a small difference in cure rate between the groups, there was no statistical difference in the outcome of both treatments. Both medications were proven to have high efficacy and cure rate. The difference with patient satisfaction between medications is Azithromycin was the preferred treatment for Pelvic Inflammatory Disease “due to the simplicity and shorter duration of its use.” (Mirblook, Asgharnia, Forghanparast, & Soltani, 2011, p. xx-xx) Successful treatment has been shown with Azithromycin but it has also proven resistant to M. genitalium which is often the leading cause of PID. “M. genitalium has demonstrated susceptibility to macrolides, azithromycin resistance has recently been reported.” (Sweet, 2011, p. xx-xx)
Relevant Psychosocial Issues
Infertility is a major concern is Pelvic inflammatory disease (PID). Because PID is an upper genital tract infection, the uterus and fallopian tubes may get damaged from complications of PID . Long-term implications of PID include “higher rates of infertility, ectopic pregnancy, and chronic pelvic pain.” (Songer, Lave, Kamlet, Frederick, & Ness, 2004, p. xx-xx) Fertility is often the most important in preserving when it comes to treatment of PID and often becomes a major goal in generating optimal treatment strategies. “About 10% of the population of childbearing age is affected by infertility.” (Songer, Lave, Kamlet, Frederick, & Ness, 2004, p. xx-xx) Although fertility plays a vital role in a woman’s emotional well being, limited research on the role infertility plays in quality of life is severely limited. Of the few reports that exists, some suggest infertility causes social isolation, depression/anxiety, and decreased or impaired job performance. In general, little is known on how infertility impacts women overall.
Public Health Implications
STIs or STDs as some will call it, are of concern to not just young women, but the overall public. STIs can cause serious side effects and aid in generation of other diseases such as PID. People need to know the relevancy of PID and sexually transmitted disease. Because PID is known to cause infertility in women, public health becomes a concern. Infertility along with the diseases that come from unprotected sex (what causes the PID, and the infertility) form a complex and expensive problem in the long run.
Millions of dollars are spent on fertility drugs, MRI’s, ultrasounds, and other additional tests, that can easily be replaced with inexpensive preventative measures. Preventative measures such as STI/STD screenings, pelvic examinations, and pap smears, allow medical professionals to detect early on any potential health problems. It is important for the public to realize the importance of preventative medicine. Preventative medicine in the long run helps women who develop diseases such as PID from running the risk of more serious issues such as infertility and ectopic pregnancy.
Patient and Family Education
Preventative measures such as IUDs for unwanted pregnancy has also been studied in regards to PID complications. In a paper written by Mohllajee, Curtis, & Peterson, they reviewed “indirect evidence from six prospective studies that examined women with insertion of a copper IUD and compared risk of PID between those with STIs at the time of insertion with those with no STIs.” (Mohllajee, Curtis, & Peterson, 2006, p. xx-xx) The six studies indicated that women with chlamydial infection or gonorrhea at the time of IUD insertion were more likely to develop PID than those with no infection. Overall, “the absolute risk of PID was low for both groups (-5% for those with STIs and 0-2% for those without).” (Mohllajee, Curtis, & Peterson, 2006, p. xx-xx) Their paper suggests that even preventative measures such as IUDs which are meant for pregnancy and not STIs, are still indicating low instances of PID leading researchers to believe women who act in a preventative way towards their health are more likely to not participate in activities that will lead to adverse health complication such as unprotected sex.
Appropriate Referral to Specialty
Appropriate treatment for women who develop PID becomes a priority. Referring a patient to a specialist is often needed. In an article by Simms et al., PID is described as having a multifactorial aetiology. “Although Chlamydia trachomatis causes a substantial proportion of cases, serological evidence has associated Mycoplasma genitalium with PID.” (Simms et al., 2003, p. xx-xx) Previous attempts at further investigation of PID have always been hindered by the lack of straightforward, precise diagnostic methods, but polymerase chain reaction (PCR) assays are presently available. “A recent Kenyan study suggested an association between M. genitalium and acute endometritis.” (Simms et al., 2003, p. xx-xx)
PID is a disease that can lead to serious consequences for women who suffer from it. The risks of infertility and/or ectopic pregnancy increase when women develop PID. Research indicates STIs, particularly C. trachomatis or Neisseria gonorrhoeae are known causes of PID. Preventative measures such as STI screenings and condom use may keep women from going through a stressful and potentially devastating ordeal. It is important to not only educate women of these risks, but also educate their family and partners. Education is key in stopping the spread of PID.
In conclusion, PID is a costly and potentially devastating disease. Priority must be placed on patient education and practitioner guidelines. If patients and medical professionals practice simplified and accurate diagnosis and adherence guidelines, early detection of PID is possible. Limited research on what methods and strategies can improve practitioner and patient adherence to PID diagnosis and management guidelines presents a problem, but new research attempts to fix that.
Interventions that make managing PID easier and more available, such as summary guidelines and plan of treatment on-site, appear to lead to better obedience but further empirical evidence is necessary. Researchers able to find new ways to approach this problem, such as studies on analysis of PID symptoms can help develop better methods for medical professionals in the near future. Hopefully with more studies and information, PID will become a disease that is not only easily treatable, but easy to diagnose early on. Preventative medicine is the key to better health.
Berger, G.S., & Westrom, L. (1992). Pelvic inflammatory disease. New York: Raven Press.
Blake, D.R., Fletcher, K., Joshi, N., & Emans, S.J. (2003). Identification of Symptoms that Indicate a Pelvic Examination is Necessary to Exclude PID in Adolescent Women. Journal of Pediatric and Adolescent Gynecology, 2003(16), 25-33. doi:10.1016/S1083-3188(02)00207-3
Landers, D.V., & Sweet, R.L. (2013). Pelvic inflammatory disease. S.l.: Springer.
Liu, B., Donovan, B., Hocking, J., Knox, J., Silver, B., & Guy, R. (2012). Improving Adherence to Guidelines for the Diagnosis and Management of Pelvic Inftammatory Disease: A Systematic Review. Infectious Diseases in Obstetrics and Gynecology, 2012(32510), 6.
Mirblook, F., Asgharnia, M., Forghanparast, K., & Soltani, M.A. (2011). A comparative study on ofloxacin and azithromycin in combination with metronidazole to outpatients with pelvic inflammatory disease. International Journal of Medicine and Medical Sciences, 13(14), 400-402.
Mohllajee, A.P., Curtis, K.M., & Peterson, H.B. (2006). Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review. Contraception, 2006(73), 145-153.
Simms, I., & Stephenson, J.M. (2000). Pelvic inflammatory disease epidemiology: what do we know and what do we need to know? Sexually Transmitted Infections, 2000(76), 80-87. Retrieved from http://sti.bmj.com/content/76/2/80
Simms, I., Eastick, K., Mallinson, H., Thomas, K., Gokhale, R., Hay, P., . . . Rogers, P.A. (2003). Associations between Mycoplasma genitalium, Chlamydia trachomatis and pelvic inflammatory disease. Journal of Clinical Pathology, 8(56), 616-618. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770020/
Smith, K.J., Cook, R.L., & Roberts, M.S. (2007). Time from Sexually Transmitted Infection Acquisition to Pelvic Inflammatory Disease Development: Influence on the Cost-Effectiveness of Different Screening Intervals. Value in Health, 10(5), 358-366.
Songer, T.J., Lave, J.R., Kamlet, M.S., Frederick, S., & Ness, R.B. (2004). Preferences for fertility in women with pelvic inflammatory disease. Fertility and Sterility, 81(5), 1344-1350.
Sweet, R.L. (2011). Treatment of Acute Pelvic Inftammatory Disease. Infectious Diseases in Obstetrics and Gynecology, 2011(561909), 1-13.
Tepper, N.K., Steenland, M.W., Gaffield, M.E., Marchbanks, P.A., & Curtis, K.M. (2013). Retention of intrauterine devices in women who acquire pelvic inflammatory disease: a systematic review. Contraception, 5(87), 655-60. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23040135
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