TREATMENT ISSUES: Special Edition - Volume 6, Number 7, Summer/Fall 1992; The Gay Men's Health Crisis Newsletter of Experimental AIDS Therapies
Garance Franke-Ruta and Mary Beth Caschetta*

Pelvic inflammatory disease (PID) is a common, yet complicated, condition which affects the upper genital tract (the fallopian tubes, ovaries, endometrial lining of the uterus, and the ligaments surrounding the upper pelvic organs). PID is a highly variable condition that can span the spectrum from a cervical infection just beginning to move up the reproductive tract, to asymptomatic (latent, showing no signs of infection) tubal infection, to acute inflammation, and abscesses (sacs of pus in the abdomen or fallopian tubes). PID can be caused by a number of organisms and can be sexually or non-sexually acquired.

Without prompt, proper diagnosis and treatment, PID can turn into a chronic health problem with constant pain or frequent flare-ups. PID that goes untreated can cause extreme pain, infertility, more frequent periods, and excessively painful periods. In its most severe forms, the disease can lead to bacteria in the blood (sepsis), spread to the liver and kidneys, and cause dangerous internal bleeding or lung failure, possibly ending in death. More than 900 women in the United States die each year from PID.[1] Approximately one million women are treated for acute PID a year.[2] It is unknown how many of these women are HIV-infected.

SYMPTOMS

The symptoms that occur in women with PID may depend on the kind of organism causing the disease. The severity of symptoms may depend on the strength of the particular strain of bacteria, the organs affected, and the woman's natural immunity to the disease. Symptoms may be mild, moderate, or severe, and may develop gradually or all of a sudden. Women with HIV-impaired immune systems may be more likely to develop chronic PID. Any of the following symptoms may occur with acute PID: stomach pain or tenderness, lower back pain, pain during or after sex, frequent need to urinate, persistent cramps, fever, chills, abnormal pain during bowel movements or urination, fatigue or weakness, cramping or stiffness of stomach muscles, swelling of lymph nodes, nausea, vomiting, headache, or rapid pulse. The pain in PID may range from a mild, bearing-down discomfort to a nagging discomfort of the lower abdomen to severe, sharp pains. The pain may be constant or may come and go. Characteristically, the pain may feel worse just before or during menstruation, and may be exacerbated by motion or walking, resulting in a 'shuffling gait.[3]

POSSIBLE CAUSES OF PID

Chlamydia and gonorrhea are the most common causes of PID. TB, an overgrowth of normal vaginal bacteria, intestinal bacteria, mycoplasmas (mainly M. hominis, but also M. genitalium, and ureaplasma urealyticum) may also cause PID although rarely.4 Nonsexually transmitted organisms are reported to cause 25% - 65% of cases of PID,s and include the organisms that cause bacterial vaginosis. Gonorrheal PID tends to occur more acutely, chlamydial PID more mildly. Because chlamydial PID produces symptoms less quickly, it can actually cause more harm from delayed diagnosis and treatment.

PID IN HIV-POSITIVE WOMEN

In a study of 110 women hospitalized with PID, a higher rate of HIV infection was found, compared to non-HIV-infected women in their community (14% vs. 2%).6 In the HIV-positive women with PID, there was a trend toward more severe disease that was treated with surgery: 27% of HIV-positive vs. 9% of HIV-negative women required surgical removal of uterus, tubes, ovaries (hysterectomy), or fallopian tubes and ovaries (salpingooopherectomy). Abscesses were present in 24% of HIV-positive women, compared to 12% in HIV- negative women. A study at San Francisco General Hospital observed 333 women with acute PID and found that their HIV-infection rate rose from 0% to 7% during 1985-1988.[7]

DIAGNOSIS

A pelvic exam is an extremely imprecise way to detect PID and is not sufficient to give an accurate diagnosis of PID when lower pelvic pain is present. Yet it is the most common method used by doctors and emergency room personnel. Upon suspecting that pelvic inflammation is present, a doctor gives a pelvic exam by pressing on the outside of the lower abdomen to feel for enlargement of the tubes or abscesses that feel hot and tender. Tenderness of the tubes and pain occurring upon removal of pressure are the two criteria used to diagnose PID.

Both chronic and acute PID are frequently mistaken for a number of other conditions, including appendicitis, ovarian cysts and tumors, ectopic pregnancy (where an embryo gets stuck developing in one of the fallopian tubes instead of going into the uterus, leading to swelling and sometimes to rupture of the tube), fibroid tumors of the uterus, and endometriosis (abnormal growth of the uterine lining outside of the uterus).

Blood tests may show elevated white blood cell counts (over 10,000--a hallmark of PID) and erythrocyte sedimentation rate (ESR) may be taken. ESR tests measure inflammation. HIV-positive women may be less likely to have an elevated white blood cell count. In the study of 110 women, HIV-positive women with PID were significantly less likely to have a white blood cell count over 10,000.[8] A pregnancy test will be done to rule out ectopic pregnancy.

A sonogram is a diagnostic test which uses sound waves instead of radiation to create an image of the internal reproductive organs and surrounding tissues. Sonograms can be used to create an image of the upper genital tract, and can provide vital information, such as the size of reproductive organs, placement of other internal organs, and the presence of unusual growths. Growths, such as abscesses, can be a sign of acute PID. The absence of growths does not mean that PID can be ruled out, but does give an indication of disease severity. A pelvic sonogram takes 10-30 minutes to perform and is completely painless, except for the internal pressure caused by the requirement for a full bladder to enhance internal imaging. A sonogram, however, is fairly expensive.

A laparoscopy is a surgical procedure by which a small microscope is surgically inserted through a l/2"-to-1" cut in the lower abdominal wall and a sample of pelvic fluid is taken for culturing. A laparoscopy may be performed instead of a sonogram, or if growths are present. A laparoscopy can be done in a walk-in hospital clinic (but usually not the gynecology clinic), hospital, or even a gynecologist's office. The site should be affiliated with a hospital, in case a woman experiences complications and needs to stay overnight. Laparoscopy generally takes 20-30 minutes. A laparoscopy is the most reliable way to diagnose PID. Some professionals recommend that all HIV-positive women complaining of lower stomach pain, lower back pain, pain upon pelvic examination and fever, should receive a laparoscopy. Unfortunately, however, it is an expensive procedure.

HOSPITALIZATION

Hospitalization is based on the presence of abscesses, pregnancy, fever, nausea and vomiting, adolescent age, use of IUD, failure to respond to outpatient therapy within 48 hours, and (these days) hospital bed availability. If a woman is diagnosed with PID and her pain has not improved substantially within 2-4 days after outpatient treatment, she should be hospitalized. Hospitalization allows the rapid administration of high levels of antibiotics in the body by IV, as well as the use of a more broad-spectrum antibiotic regimen. Hospitalization also allows laparoscopy that is used to diagnose tubo-ovarian abscesses and any other emergency surgery necessary to remove severe inflammation. If IV medication is not needed, outpatient treatment is recommended.

TREATMENT

The goals of PID treatment are to prevent relapses and preserve fertility. Nevertheless, 20% - 25% of women will have a recurrence of PID,[9] usually due to a new or repeat infection from untreated or new partners. Once the cellular lining of the fallopian tubes has been disturbed by an infection, it is thought to make it easier for bacteria to take hold in the future. Treatment failures may also occur because of the rising frequency of antibiotic-resistant bacteria.[10]

The latest (1989) CDC guidelines for outpatient treatment of PID are as follows: One dose of ceftriaxone (250 mg injected into a muscle) followed by 10-14 days of either doxycycline (100 mg twice a day) or erythromycin (500 mg four times a day). Cefoxitin must be administered with 1 gm probenecid to increase the amount of time it stays in the body. This will also increase the amount of time other drugs--like AZT--are in the body, and may lead to side effects unless doses are briefly adjusted. After treatment is completed, repeat cervical cultures are done, or, less commonly, repeat exploration of the upper genital tract with a laparoscopy is performed. A repeat sonogram may be performed to see if abscesses and swelling have resolved. However, there is no standard definition of a cure for the disease.

Almost no information has been published about the treatment of PID in HIV-infected women. Giving large doses of broad-spectrum drugs (overmedicating) may be the only way to assure that all disease-causing organisms are eradicated. Nausea and yeast infections are common during PID treatment.

Finally, combination use of electric acupuncture and moxibustion (heat therapy) in the treatment of 95 cases of chronic PID was reported to cure 42 women, improve 39, and have no effect in 12. The overall improvement rate of 88.4% was superior to a control group using antibiotics.[11]

TREATMENT BY SURGERY

Surgery is used in the case of massive inflammation and abscesses. There may be a tendency to be freer with the use of surgery and hysterectomy in an HIV-positive woman, as doctors may feel less hesitant in removing her ability to have children. This may lead to rapid "pelvic sweeps" (total hysterectomy where all upper reproductive organs are removed), rather than antibiotic treatment followed by a conservative use of surgery. Hysterectomy is a major operation requiring a few weeks' hospital stay and months of healing. Treatment first seems to be the more humane way to approach PID, unless the woman indicates otherwise.

PREVENTING PID

Sexually-transmitted PID is often preventable. Coming in contact with sexually-transmitted organisms that cause PID can usually (but not always) be prevented with constant condom use by male sexual partners. Menstrual blood and sperm both provide a vehicle for PID organisms to "hitchhike" up the reproductive organs. During menstruation, the lining of the uterus is disturbed and there is ample blood to create the ideal growth environment for these blood-loving bacteria. Refraining from sex during menstruation may reduce the risks of getting sexually-transmitted PID. The use of barrier contraceptives such as the condom, the diaphragm, and the cervical cap all keep most bacteria and sperm from traveling into the uterus, and have been shown to be associated with a reduced risk of PID in HIV-negative women.

CONCLUSION

Ultimately, the occurrence and severity of PID is most related to access to preventive health care and adherence to safer sex measures. Early diagnosis, aggressive and humane treatment, as well as regular monitoring for PID and STDs are desperately needed and, unfortunately, in short supply.

FOOTNOTES ---------

1. Moore, M. PID:The Silent Epidemic, Healthsharing, p.8, 1986.

2. Sweet, L.R., Pelvic inflammatory disease and infertility in women. Sexually Transmitted Diseases in Infectious Dis Cli of No Amer 1(1):199-215, 1987

3. Labadie, L.L., et al. Management of genital infections. Obstric and Gynecologic Emergencies in Emergency Medicine Clinics of North America 5(3):443, 1987

4. Sweet, L.R., op cite.

5. Sweet, L.R., op cite.

6. Hoegsberg, B. et al. Sexually transmitted diseases and human immunodeficiency virus infection among women with pelvic inflammatory disease. Am J Obstet Gynecol 163(4)1:113539, 1990

7. Safrin, S. et al. Seroprevalence and epidemiological correlates of human immunodeficiency virus infection in women with acute PID. Obst Gynecol 75(4):666-70, 1990

8. Hoesgberg, B. et al. op cit.

9. Hoesgberg, B. et al. op cit.

10. Ibid.

11. Wang, XM. On the therapeutic efficacy of electric acupuncture with moxibustion in 95 cases of chronic pelvic inflammatory disease (PID). J Trad Chin Med 9(1):21-4, 1989.

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