Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is an infection of the upper female genital tract: the womb, the fallopian tubes, the ovaries and the tissue around them.
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Medicines commonly prescribed for Pelvic inflammatory disease
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: INJECTABLE, 1 g ceftriaxone disodiumActive substance: ceftriaxoneManufacturer: Fresenius Kabi España, S.A.U.Prescription requiredDosage form: INJECTABLE PERFUSION, 2 g sodium ceftriaxoneActive substance: ceftriaxoneManufacturer: Laboratorios Normon S.A.Prescription requiredDosage form: INJECTABLE, 1 gActive substance: ceftriaxoneManufacturer: Medochemie LimitedPrescription required
Pelvic inflammatory disease (PID) is an infection of the upper female genital tract: the womb, the fallopian tubes, the ovaries and the tissue around them. The bacteria almost always travel upwards, from the vagina and the cervix. What makes the illness treacherous is how mild it often feels: an ache low in the abdomen, a change in discharge, discomfort during sex, and little else. Meanwhile scarring builds up inside the tubes, and that scarring is what later makes pregnancy difficult. So speed matters more than precision here: treatment is started before the laboratory results come back.
How the infection reaches the womb and tubes
The cervix works as a gate and normally keeps microbes from travelling higher. When that gate fails, inflammation begins. The causes fall into two groups.
Sexually transmitted infections. The commonest cause is chlamydia and gonorrhoea, and increasingly Mycoplasma genitalium alongside them. These bacteria live at first only in the cervix, where they are easy to clear. But if the infection goes unnoticed and untreated, a proportion of cases travel upwards within a few months.
The woman's own vaginal bacteria. In many cases no sexually transmitted infection is found at all. The culprits are then the ordinary vaginal bacteria — harmless where they belong, but capable of causing inflammation if they get into the womb. This usually happens when the cervix has been open: after childbirth, a miscarriage or a termination, after an intrauterine device has been fitted (the risk is higher in the first few weeks), or after procedures inside the uterine cavity.
The risk is higher with a new partner or several partners, after previous sexually transmitted infections or a previous episode of inflammation, and at a young age: under twenty-five PID is considerably more common. Rarely is one microbe to blame — usually several are involved at once, which is why treatment is a combination of drugs.
What it feels like
There may be nothing striking at all: some women find out they have had PID years later, when they are being investigated for difficulty conceiving. When there are symptoms, they usually run like this:
- a dull ache low in the abdomen or in the pelvis, most often on both sides;
- pain during sex, felt deep inside rather than at the entrance to the vagina;
- a change in vaginal discharge: heavier, yellow or greenish, with an odour;
- bleeding between periods or after sex, and periods that have become heavier and more painful;
- burning and needing to pass urine more often;
- a slightly raised temperature, tiredness, aching.
One detail explains why PID is so often missed: the pain is rarely sharp and pinpointed. It is dull, smeared across the lower abdomen, and worse with movement and towards the evening. Such pain is easily put down to having got cold or to the period itself, and weeks are lost that way.
When help is needed straight away
Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single number is 112) or go to an emergency department if:
- the abdominal pain is sudden and severe, is getting worse, or spreads to the shoulder;
- the temperature is above 38.5 °C with shivering, vomiting and an inability to keep fluids down;
- you feel faint or dizzy, your vision darkens, you black out, or your skin turns cold and clammy;
- the abdomen becomes hard and hurts at the lightest touch;
- there is abdominal pain with a missed period or a positive pregnancy test — this can be an ectopic pregnancy, where the timescale is hours, not days;
- heavy vaginal bleeding starts.
See a doctor the same day, though without an ambulance, if pain low in the abdomen persists, if the discharge has changed, or if a temperature appears after a recent birth, a termination or the fitting of an intrauterine device. Every week of delay adds to the risk that the tubes will be damaged.
How the diagnosis is made
There is no simple test that answers yes or no, and it is worth knowing that in advance. The diagnosis is a clinical one: it rests on the combination of symptoms and examination findings, and treatment starts without waiting for the laboratory.
- Vaginal examination. The key finding is tenderness when the cervix is moved and over the tubes and ovaries. You can ask for a chaperone and stop the examination at any point.
- Swabs from the vagina and cervix for chlamydia, gonorrhoea and mycoplasma by molecular methods. A positive result confirms the diagnosis. A negative one does not rule it out: in most women with PID the swabs are clear, because the infection has already moved higher up.
- A pregnancy test — essential, so that an ectopic pregnancy is not missed.
- Pelvic ultrasound, usually with a vaginal probe. A normal scan does not exclude inflammation; the scan is mainly there to find an abscess in a tube or ovary and to rule out other causes of pain.
- Laparoscopy — looking at the pelvic organs with a camera through a small cut. It is used rarely: when the diagnosis is unclear, the illness is severe, or a surgical condition is suspected.
Testing for other sexually transmitted infections, including HIV and syphilis, is offered at the same time, as they often travel together.
What else it can be
Pain low in a woman's abdomen is one of those symptoms with a dozen possible explanations behind it. Before settling on inflammation, a doctor thinks through the following:
- ectopic pregnancy — ruled out first, because it is life-threatening;
- appendicitis — pain more often on the right, moving out from around the navel, with nausea and loss of appetite;
- a twisted or ruptured ovarian cyst — pain that comes on within minutes, usually on one side;
- endometriosis — cyclical pain, tied to periods over years;
- urinary infection and kidney infection — burning on passing urine, loin pain, fever;
- irritable bowel syndrome and diverticulitis — pain linked to bowel habit and food;
- chronic pelvic pain without infection — antibiotics do not help here, and repeated courses only waste time.
One uncommon but recognisable extension of the illness deserves separate mention: the inflammation can reach the membrane around the liver and cause pain under the right ribs that spreads to the shoulder. Such pain is readily mistaken for a gallbladder problem when the source is in the pelvis.
How it is treated
Antibiotics are the mainstay, and they are started at once, before any results are back. Not a single drug but a combination is prescribed: it has to cover both the sexually transmitted organisms and the anaerobic bacteria of the vagina. Typically that means one injection of a cephalosporin antibiotic followed by two weeks of tablets — a tetracycline together with metronidazole. Regimens differ, but the length is almost always around a fortnight.
What matters while you are on the course:
- finish it, even if you feel better after three days: a half-treated infection returns and damages the tubes;
- tell the doctor if pregnancy is possible — some of these drugs are not used in pregnancy, and treatment will be different, usually in hospital;
- avoid alcohol while taking metronidazole, and stay out of strong sunlight, as tetracyclines make the skin more sensitive;
- avoid sex until both you and your partner have finished treatment.
Paracetamol is suitable for the pain. Ibuprofen and other anti-inflammatory painkillers are taken in short courses and with food; they are best avoided with a stomach ulcer or kidney disease, and in pregnancy any painkiller should be agreed with a doctor first.
At around three days the doctor reviews whether the treatment is working; if there has been no improvement, further tests and usually admission are needed. Hospital care is arranged in pregnancy, in severe illness, when an abscess is suspected, and when a surgical condition cannot be ruled out. If you have an intrauterine device and there is no improvement within a few days, removing it is discussed, and an abscess sometimes has to be drained.
Partners, and not catching it again
Treating the woman alone does not end the story. All sexual partners from the past six months should be tested and treated, even when no specific organism was ever identified and even when the partner has no symptoms at all: in men chlamydia usually causes none. If there has been no partner in that time, it is the most recent one who needs testing.
PID also occurs in long-standing couples where neither has had sex with anyone else, so it is not grounds for blame. But if only one of you is treated, the infection comes straight back once sex resumes. A doctor can help notify previous partners, anonymously if you prefer.
For the future, the simple measures work: condoms with a new partner until you have both been screened; testing when partners change rather than only when something hurts; and a check before any planned procedure inside the womb. Chlamydia is common and almost always silent, so "nothing is bothering me" is no proof that there is no infection.
What happens if it is left
Most women who start treatment promptly and complete the course have no lasting consequences. Problems arise in those who delayed treatment or who have had inflammation several times.
- repeated episodes: each one lands on already damaged tissue and is harder to get over;
- an abscess in a tube or ovary — this needs intravenous antibiotics and sometimes drainage, and if it bursts it is life-threatening;
- adhesions and blocked tubes: scarring stops the egg reaching the womb;
- ectopic pregnancy — the risk after PID is appreciably higher than usual;
- difficulty conceiving; surgery can help with blocked tubes, and where it cannot, in vitro fertilisation is an option;
- chronic pelvic pain that persists once the infection has gone: what is needed then is not more antibiotics but pain management and work with a chronic pain specialist.
If pregnancy does not happen within a year after an episode of PID — or within six months if you are over thirty-five — it is worth having the tubes checked without further delay.
Online consultation
An online appointment is a good way to work out which way to move. The doctor will ask in detail where and for how long it has been hurting, what has changed about discharge and periods, whether there has recently been a birth, a termination, a coil fitting or a new partner — and will say whether emergency care is needed, whether it can wait until morning, or whether you need to be examined today.
Online is also a convenient place to go through results you already have: swabs, blood tests, a scan report. The doctor can explain why a negative swab does not remove the diagnosis, why there are three drugs in the regimen at once, and what to do about the side effects that make people abandon the course halfway. A separate and very common topic is how to tell a partner that they need testing too.
What cannot be done online: a vaginal examination, taking swabs and performing a scan — and without an examination the diagnosis of PID is not made. And if any of the signs in the emergency section appear, do not send a message — call an ambulance.
This material is for information only and does not replace medical advice.
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