Pelvic Inflammatory Disease (PID) - CDC Fact Sheet
Basic Fact Sheet | Detailed Version
Detailed fact sheets are intended for physicians and individuals with specific questions about sexually transmitted diseases. Detailed fact sheets include specific testing and treatment recommendations as well as citations so the reader can research the topic more in depth.
What is pelvic inflammatory disease?
Pelvic inflammatory disease (PID) is a clinical syndrome that results from the ascension of microorganisms from the cervix and vagina to the upper genital tract. PID can lead to infertility and permanent damage of a woman’s reproductive organs.
How do women get pelvic inflammatory disease?
Women develop PID when certain bacteria, such as chlamydia or gonorrhea, move upward from a woman's vagina or cervix into her reproductive organs. PID is a serious complication of some sexually transmitted diseases (STDs), especially chlamydia and gonorrhea.
What causes pelvic inflammatory disease?
Many different types of microorganisms can cause PID; therefore, it is a considered a polymicrobial infection. Most cases of PID are caused by gonorrhea and chlamydia. Sexually transmitted disease pathogens Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) have frequently been identified among women with PID infection and these microbes have accounted for a third to a half of the cases 1,2 While the focus has been on the role played by STDs, especially CT in the etiology of PID, endogenous microorganisms, including gram positive and negative anaerobic organisms and aerobic/facultative gram positive and negative rods and cocci, found at high levels in women with bacterial vaginosis, also have been implicated in the pathogenesis of PID 3,4 Newer data suggest that Mycoplasm genitalium may also play a role in PID and may be associated with milder symptoms 5,6 Because of this polymicrobial nature, broad-spectrum regimens that provide adequate coverage of likely pathogens are recommended.
What are the signs and symptoms of pelvic inflammatory disease?
Since some women with PID have subtle or mild symptoms, many episodes of PID can go unrecognized by women and their health care providers. Women with PID present with a variety of clinical signs and symptoms that range from subtle and mild to severe. Some of the signs and symptoms associated with acute PID are nonspecific, so it is important to consider other reproductive tract illnesses and diseases of both the urinary and the gastrointestinal tracts during an evaluation of a sexually active female with lower abdominal pain. Pregnancy must also be excluded. A pregnancy test should always be performed to exclude ectopic pregnancy and because PID can occur concurrently with pregnancy. In the case of subclinical PID, women have mild or no pelvic pain, despite evidence of endometritis or salpingitis.7
When symptoms are present, the most common symptoms of PID are
- Lower abdominal pain
- Mild pelvic pain
- Increased vaginal discharge
- Irregular menstrual bleeding
- Fever (>38° C)
- Pain with intercourse
- Painful and frequent urination
- Abdominal tenderness
- Pelvic organ tenderness
- Uterine tenderness (along with endometriosis)
- Adnexal tenderness (along with salpingitis)
- Cervical motion tenderness
What are the complications of pelvic inflammatory disease?
The risk of developing short and long-term complications from PID depends upon the severity and number of episodes of PID, thereby emphasizing the importance of prompt and appropriate treatment.
Complications of PID include
- Scarred fallopian tube
- Tubo-ovarian abscess (TOA)
- Tubal factor infertility
- Ectopic pregnancy
- Pelvic adhesions
- Chronic pelvic pain
Complications of PID such as chronic pelvic pain and scarring are difficult to treat but sometimes improve with surgery.
Tubo-ovarian abscess (TOA) is a serious short-term complication of PID that is characterized by an inflammatory mass involving the fallopian tube, ovary, and, occasionally, other adjacent pelvic organs. The microbiology of TOAs is similar to PID and the diagnosis necessitates initial hospital admission. Treatment includes broad-spectrum antibiotics with or without a drainage procedure, with surgery often reserved for patients with suspected rupture or who fail to respond to antibiotics. Women infected with HIV may be at higher risk for TOA. Mortality from PID is less than 1% and is usually secondary to rupture of a TOA or to ectopic pregnancy.
How is pelvic inflammatory disease diagnosed?
There are no tests specifically for diagnosing PID. Because the diagnosis of PID can be imprecise, clinicians should have a high index of suspicion for the diagnosis. Physical examination findings to detect PID can also vary, and there is no single finding that is sensitive and specific for the diagnosis. When the diagnosis of PID is questionable, or when the illness is severe or not responding to therapy, further investigation may be warranted using other invasive procedures (endometrial biopsy, transvaginal ultrasonography or magnetic resonance imaging, and/or laparoscopy).
What medical examinations and assessments can be performed to diagnose pelvic inflammatory disease?
Clinical providers should perform a physical examination assessing the abdomen for tenderness. Other assessments may include evaluation of the vaginal pH, a whiff test (performed by adding a small amount of potassium hydroxide to a microscopic slide containing the vaginal discharge), and microscopy of the vaginal secretions for the presence of leukocytes, clue cells, and trichomonads.
The cervix should be examined for abnormal cervical and vaginal discharge, and friability. An internal exam should be performed to assess for pelvic organ tenderness and/or a mass. A clinician should also check for fever and for laboratory documentation of cervical infection with NG and CT. However, laboratory confirmation is not necessary to justify initiation of therapy for PID.
A serologic test for human immunodeficiency virus (HIV) is also recommended. A pregnancy test should always be performed to exclude ectopic pregnancy and because PID can occur concurrently with pregnancy. When the diagnosis of PID is questionable, or when the illness is severe or not responding to therapy, further investigation may be warranted using other invasive procedures (endometrial biopsy, transvaginal ultrasonography, magnetic resonance imaging, or laparoscopy).
A bimanual pelvic examination can be performed and may reveal pelvic organ tenderness, uterine tenderness in the case of endometritis, and adnexal tenderness in the case of salpingitis.
Cervical motion tenderness is another common finding in women with PID. Assessment of the lower genital tract (mucopurulent cervical discharge or evidence of WBCs on a microscopic evaluation of a saline preparation of vaginal fluid) can also yield signs of inflammation, which are consistent with the diagnosis of PID.
How is pelvic inflammatory disease treated?
Several types of antibiotics can cure PID. Antibiotic treatment does not, however, reverse any scarring caused by the infection. For this reason, it is critical that a woman receive care immediately if she has pelvic pain or other symptoms of PID. Prompt antibiotic treatment can prevent severe damage to the reproductive organs. The longer a woman delays treatment for PID, the more likely she is to become infertile or to have a future ectopic pregnancy because of damage to the fallopian tubes.
PID is usually treated with antibiotics to provide empiric, broad spectrum coverage of likely pathogens. Recommended regimens can be found in the 2010 STD Treatment Guidelines. Health care providers should emphasize to their patients that although their symptoms may go away before the infection is cured, they should finish taking all of the prescribed medicine. Additionally, a woman’s sex partner(s) should be treated to decrease the risk of re-infection, even if the partner(s) has no symptoms. Although sex partners may have no symptoms, they may still be infected with the organisms that can cause PID.
In certain cases, clinicians may recommend hospitalization to treat PID. This decision should be based on the judgment of the health care provider and the use of suggested criteria found in the 2010 STD Treatment Guidelines. If a woman’s symptoms continue, or if an abscess does not resolve, surgery may be needed.
What should a patient do after being diagnosed with pelvic inflammatory disease?
A patient should abstain from sexual intercourse until she and her partner(s) have completed treatment. Female latex condoms are also an option if a woman prefers them or if her male partner chooses not to use male condoms. Women who are told they have an STD and are treated for it should notify all of their recent sex partners so they can see a health care provider and be evaluated for STDs.
The diagnosis of PID provides an opportunity to educate adolescent and young women about prevention of STDs, including abstinence, consistent use of barrier methods of protection, immunization, and the importance of receiving periodic screening for STDs and HIV.
How can pelvic inflammatory disease be prevented?
Latex condoms may reduce the risk of PID. Treating STDs early can prevent PID. Since STDs play a major role in PID, screening and early treatment of infected women and their sex partners can help to minimize the risk of acquisition and continued transmission of STDs and subsequent adverse sequelae. Identifying, testing, and treating women at increased risk of cervical chlamydial infection can reduce the incidence of PID.8, 9
Consistent and correct use of latex male condoms can reduce the risk of transmission of chlamydia and gonorrhea and the risk of PID.
CDC recommends that providers screen the following populations for chlamydia: all sexually active women age 25 or younger annually, older women with risk factors for chlamydial infections (those who have a new sex partner or multiple sex partners), and all pregnant women during the first prenatal visit.
What are the risk factors for developing pelvic inflammatory disease?
Risk factors are important considerations in both the clinical management and prevention of upper genital tract infections. As STDs are the most common etiological agents for PID, risk factors for developing PID can be related to those associated with the acquisition of STDs, including early coitarche, young age, alcohol use, inconsistent use of barrier contraceptives, and multiple sexual partners or having one partner with multiple sexual partners.10 Other factors that have been associated with PID include a prior history of PID, intrauterine device use (IUD) (risk seems to be primarily restricted to the first several weeks following insertion), and douching.
Is the number of women in the United States being diagnosed with pelvic inflammatory disease increasing?
No. Over the last decade, there have been several studies published suggesting overall declines in PID diagnosis in both hospital and ambulatory settings.11-13 While no single explanation exists for this declining trend, some have suggested that changes in sexually transmitted disease (STD) rates, increases in chlamydia screening coverage, availability of antimicrobial therapies that increase adherence to treatment, and more sensitive diagnostic technologies, could be impacting PID rates.14
Despite declining trends, PID is a frequent and important infection that occurs among women of reproductive age. Based on a nationally representative sample from 2006-2010, approximately 4.2% of U.S. women have reported being treated for PID in their lifetime.15
The significant burden of disease attributed to PID comes predominantly from the long-term reproductive sequelae of tubal infection: tubal factor infertility, ectopic pregnancy, and pelvic adhesions, which can lead to chronic pelvic pain. Our knowledge of the longitudinal outcomes for affected women who experience PID is primarily derived from data published using a Scandinavian cohort of inpatients diagnosed with PID. 16, 17 Data from this study indicated that those women with PID were more likely to have ectopic pregnancy (6 times increased rate), tubal factor infertility (ranging 8% after first episode to as high as 40% after three episodes) and chronic pelvic pain (18% following 1 episode).
What is the economic burden of pelvic inflammatory disease in the United States?
A decline in incidence of PID is also reflected in the most recent cost estimates of PID and its sequelae. Direct medical expenditures for PID and its sequelae were estimated at $1.88 billion in 199818, compared to approximately $2.7 billion estimated in 1990.19 Based on a nationally representative sample from 2006-2010, approximately 4.2% of U.S. women have reported being treated for PID in their lifetime.15
How can clinicians manage PID?
A critical component to the outpatient management is short-term follow-up, especially in the adolescent population. Since many adolescent women rely on outpatient services for the evaluation and treatment of STD symptoms, the need for a low diagnostic and management threshold for PID is even more critical, as the likelihood for additional follow-up care is low.
1 Haggerty CL, Ness RB. Epidemiology, pathogenesis and treatment of pelvic inflammatory disease. Expert Rev Anti Infect Ther. 2006;4:235-47.
2 Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol. 2002;186:929-37.
3 Hillier SL, Kiviat NB, Hawes SE, et al. Role of bacterial vaginosis-associated microorganisms in endometritis. Am J Obstet Gynecolo 1996;175;435-41.
4 Eschenbach DA, Buchanan TM, Pollock HM, Forsyth PS, Alexander ER, et al. Polymicrobial etiology of acute pelvic inflammatory disease. N. Engl J Med. 1975;293:166-171.
5 Simms I, Eastick K, Mallinson H, et al. Association between Mycoplasma genitalium, Chlamydia trachomatis and pelvic inflammatory disease. J Clin Pathol 2003;56:616.618.
6 Cohen CR, Mugo NR, Astete SG, et al. Detection of Mycoplasma genitalium in women with laparoscopically diagnosed acute salpingitis. Sex Transm Infect. 2005;81:463-466.
7 Wiesenfeld HC, Hillier SL, Meyn LA, et al. Subclinical pelvic inflammatory disease and infertility. Obstet Gynecol. 2012;120:37-43.
8 Scholes D, Stergachis A, Heidrich FE, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med. 1996;334:1362–1366.
9 Oakeschott, P, Kerry S, Aghaizu A, et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ. 2010;340:c1642.
10 Berman SM, Holmes KK. Sexually Transmitted Diseases, ed. S.P. Holmes KK, Mardh PA, et al., 1999, New York: McGraw-Hill.
11 Bohm MK, Newman L, Satterwhite CL, et al. Pelvic inflammatory disease among privately insured women, United States, 2001–2005. Sex Transm Dis. 2010;37:131–136.
12 Centers for Disease Control and Prevention (DCDC). STDs & infertility. 2011. Available at http://www.cdc.gov/std/infertility/. Accessed August 14, 2013.
13 Sutton MY, Sternberg M, Zaidi A, et al. Trends in pelvic inflammatory disease hospital discharges and ambulatory visits, United States, 1985-2001. Sex Trans Dis. 2005;32:778-84.
14 Owusu-Edusei K Jr, Bohm MK, Chesson HW, et al. Chlamydia screening and pelvic inflammatory disease: insights from exploratory time-series analyses. Am J Prev Med. 2010;38:652–657.
15 Westrom, L. Effect of acute pelvic inflammatory disease on fertility. Am J of Obstet & Gynecol. 1975;121:707-13.
16 Westrom L, Joesoef R, Reynolds G, et al. Pelvic inflammatory disease and fertility. Sex Trans Dis. 1992;19(4):185-192.
17 Rein, D B. Kassler, W J. Irwin, et al. Direct medical cost of pelvic inflammatory disease and its sequelae: decreasing, but still substantial. Obstet & Gynecol. 2000;95:397-402.
18 Washington AE, Katz P. Cost of and payment source for pelvic inflammatory disease. Trends and projections, 1983 through 2000. JAMA. 1991;266:2565–9.
19 Leichliter JS, Chandra A, Sevgi OA. Correlates of self-reported pelvic inflammatory disease treatment in sexually experienced reproductive-aged women in the United States, 1995 and 2006-2010. Sex Trans Dis. 2013;40:413-418.