Prevention of Complications of PID

Roberta B. Ness, M.D., M.P.H.

University of Pittsburgh

Graduate School of Public Health

What is Pelvic Inflammatory Disease (PID)?

•Infection involving the uterus, fallopian tubes, ovaries or other upper genital tract sites

•Most often caused by Chlamydia and Gonorrhea

•Other STDs and lower genital tract infection may cause PID

Why worry about PID

•Morbid

•Common

•By the time symptoms

manifest it may be too late!

“… Then in 1975, I had a bout of painful cramps which, as it turned out, were caused by a severe infection. My horrified gynecologist took out the IUD and prescribed large doses of antibiotics. He also warned me that I might have trouble having children.”

From: “A cash settlement but no apology”

NY Times 2/99

“He was right, though I didn’t find out for more than a decade. I had to fall in love, get married and spend a few years trying to conceive before an X-ray showed that my fallopian tubes were scarred and completely blocked. My husband and I tried in-vitro fertilization three times but were unsuccessful in having children.” From: “A cash settlement but no apology”

NY Times 2/99

PID and Infertility

•One fifth of women who have at least one episode of PID may become infertile

•Half of women with three or more episodes of PID may become infertile

Infertility Prevalence

• 4.9 million women aged 15-44

• 2.2 million women without children

Causes of Infertility and Rates of Pregnancy during Follow-up in the United StatesCause Prevalence (%) Pregnancy Rate (%)

Ovulatory failure 16 44

Tubal damage 12 26

Semen factor 18 38

Endometriosis 25 31

Unexplained 17 55

Multiple 28 -

All - 38

From Jones HW, Toner JP. The infertile couple. N Engl J Med 1993:1710-1715.

PID and Chronic Pelvic Pain

• One fourth of women with acute PID may experience subsequent chronic pelvic pain

PID and Ectopic Pregnancy

• One in ten women may have an ectopic pregnancy in their first pregnancy following PID

•Tubal pregnancy is the leading cause of first-trimester, pregnancy-related deaths in American women

Prevalence of PID

• 8% of all American women of reproductive age are reported to have received treatment for PID in 1995

• Over one million American women seek treatment for PID annually

The Incidence of STDs

• 333 million new cases of curable STDs globally

• U.S. rates are 50 – 100 times higher than other industrialized nations

• 85% of the most common infectious diseases in the U.S. are sexually transmitted

Incidence of STDs in the U.S.

• 12 million new cases of STDs in the U.S. yearly

• 3 million of these cases are among teenagers

Gonorrhea – Reported rtes: United States, 1970 –1997 and the Healthy People year 2000 Objective

Gonorrhea

2000 objective100

300

500Rate (per 100,000 population)

1970 19971976 1982 1988 1994CDC

Symptoms of Chlamydia

• Many infected individuals experience no symptoms

• 75% of women experience no symptoms• Men: watery or milky discharge from the

urethra, painful urination• Women: Painful urinary, increased

vaginal discharge, possible light bleeding between periods

Bacterial STDs and Pelvic Inflammatory Disease

Tertiary Prevention PEACII

Secondary Prevention DAISY

Primary Prevention GIFT

Prevention

Stop AIDS

When the opportunity for prevention is missed ……

Diagnosis and Treatment of PID

Pelvic examination Test for STDs Outpatient antibiotic therapy Inpatient therapy 200,000 to 300,000 women

hospitalized will undergo surgery

Guidelines for hospitalization

The guidelines for making the determination about whether a women should be hospitalized or not, which have been published by the CDC, are a little open to interpretation. If the diagnosis is uncertain, which it almost always is, then you can consider hospitalizing the women for PID. If a patients is an adolescent, gets severe illness, this precludes outpatients management. A clinician would have a lot of flexibility in interpreting these guidelines.

What Factors Influence the Decision to Hospitalize patients with PID?

R. Ness, K. Delaney, R. Rolfs, J. Gale

Hospitalization from Two Hospital-based Settings versus Non-Hospital Setting

• Emergency Department 21%

• Hospital-Based Clinics 26%

• Out-of Hospital Clinics 3.5%

• Results suggest that hospitalization for PID is considered to be largely discretionary

• Reflects uncertainty about the relative effectiveness of outpatient versus inpatient treatment