Understanding and treating pelvic inflammatory disease (PID)

Pelvic inflammatory disease (PID) is a condition where pelvic tissue is inflamed and painful. Most often, a bacteria is responsible, having invaded the upper reproductive tract. Some people with PID may not have a current or previous microbial infection, but most do.

If left undetected or untreated or if bacteria are treatment-resistant, damage can occur to reproductive organs due to ongoing inflammation and scarring. Rapid diagnosis, treatment and ongoing monitoring are required to ensure resolution of the infection and inflammation.

Risk factors for developing pelvic inflammatory disease

The risk factors for PID are multiple sexual partners, increasing the risk of a STI, douching, and the implantation of an intrauterine device (IUD)^​1​.

Having an unstable or weakly protective vaginal microbiome may contribute to the risk, as does an endometriosis diagnosis^​2,3​.

We also have evidence^​4​ that suggests the vaginal and rectal microbiomes may also play a role in PID. People with PID have less protective and more inflammatory vaginal and rectal microbiomes than people without PID.

In a lab model, bacterial vaginosis (BV) related bacteria, Fannyhessea vaginae, caused inflammation in the fallopian tube tissue, while Lactobacillus crispatus, a known protective vaginal species, did not^​5​.

Eating an inflammatory diet was also strongly associated with PID^​6​.

Bacteria and PID

Many bacteria can contribute to PID, such as a sexually transmitted infection (STI), the two main culprits being chlamydia and gonorrhoea,

But, PID can be caused by many other types of bacteria, such as Escherichia coli (E. coli).

The most common microbial causes of PID include:^​1​

• Neisseria gonorrhoeae (tends to be more severe than from other causes)
• Chlamydia trachomatis (less likely to cause symptoms than gonorrhoea)
• Mycoplasma genitalium
• Peptostreptococcus species
• Bacteroides species
• Haemophilus influenza
• Streptococcus pneumonia
• Staphylococcus aureus
• Escherichia coli
• Bacteroides fragilis
• Group B Streptococci

Understanding the pain of PID

The causes of pelvic pain still remain mysterious. Pain is caused by stimuli and activation of nociceptors in nerve endings and results in inflammation and tissue damage, resulting in pain.

Proinflammatory markers have a direct impact on central sympathetic nervous system activity and nociceptive nerve fibres. Many interconnections exist between the pelvic structures, the nervous system, and pelvic organs.

Chronic pelvic pain is associated with disruptions to the hypothalamic–pituitary–adrenal (HPA) axis dysregulation and central sensitisation^​7​. Disturbances to the central processing of pain and viscerosensory signals play a role in PID, with specific nerves carrying sensory information from the pelvis to the brain.

The consequences of chronic pelvic pain are far-reaching, affecting a person’s emotional, behavioural, cognitive and sexual health and well-being. Chronic pelvic pain is a quality-of-life issue.

Diagnosing PID

There isn’t a single test for PID, and it isn’t exactly a ‘disease’, rather a condition of inflammation in the pelvis that can have multiple causes. Those between the ages 15-25, and presenting with lower abdominal or pelvic pain, vaginal discharge, painful sex and/or abnormal vaginal bleeding are suspected of PID.

Risk factors for developing PID include having multiple sexual partners, age, having had PID previously, IUDs, and tubal ligation. A physical examination is crucial. Cervical discharge, cervical motion tenderness, uterine tenderness, adnexal tenderness or masses should be evaluated during the examination. A wet prep should be evaluated for white blood cells or cervical friability.

Tests that are likely to be performed include a pregnancy test for ectopic pregnancy or another cause of the pain. Microscopy of vaginal or cervical discharge should be performed with the latest DNA/RNA testing methods and an STI panel run. An ultrasound may be considered.

Signs and symptoms of PID

• Lower abdominal pain
• Cervical motion tenderness (an examination technique)
• Fever
• Unusual discharge with foul odour
• Pain or bleeding during or after sex
• Burning with urination
• Bleeding between periods
• Elevated CRP on a blood test
• Painful sex
• Adnexal and uterine tenderness

In one study^​8​ of people who ended up in the emergency room with PID, 35% had a tubo-ovarian abscess, with over 50% having a pathogen found, and out of those, 70% had a finding of E. coli. Not all testing methods will reveal the specific bacteria.

Treatment of PID

The goal of treatment of PID is to alleviate pain and symptoms caused by infection, to eradicate microbial infections, and prevent further spread. Antibiotics have specific adverse effects on the human body, and thus, drug treatments can be replaced with safer alternatives as they become more widely available, such as botanicals^​9,10​ and complementary and alternative treatments^​9,11​.

Antibiotics for underlying pelvic infection

PID is treatable by treating the underlying infection, typically with antibiotics determined by the type of bacteria found.

If the most common tests (such as culture) do not find bacteria, ask for a more sensitive PCR or NGS test of the affected tissue, where possible.

Empiric treatment for PID in the inpatient setting includes^​1​:

• Cefotetan (2 g intravenously [IV] every 12 hours) plus doxycycline (100 mg by mouth every 12 hours) or
• Cefoxitin (2 g IV every 6 hours) plus doxycycline (100 mg by mouth every 12 hours) or
• Clindamycin (900 mg IV every 8 hours) plus gentamicin (3 to 5 mg/kg IV once daily)

The CDC recommends the following for first-line treatment for outpatient therapy^​1​:

• Doxycycline (100 mg orally twice a day for 2 weeks) plus ceftriaxone 500 mg intramuscularly (IM) for one dose or cefoxitin 2 g IM with probenecid (1g orally) for one dose or another parenteral third-generation cephalosporin

Metronidazole (500 mg orally twice per day for 14 days) should be added if there is a concern for trichomonas or recent vaginal instrumentation.

Herbal medicine for pelvic inflammatory disease

The rose and black sesame powder pessary experiment

Herbal medicine has been utilised in therapeutic doses with promising results^​9,10​.

In particular, one study^​10​ on uncomplicated pelvic inflammatory disease demonstrated that sesame (Sesamum indicum) linn seeds and Rosa damascena mill oil provided a clinical cure that is equivalent to an antibiotic treatment.

Black sesame seeds have natural antibacterial effects against Staphylococcus and Streptococcus species, alongside antifungal, antiviral and anti-inflammatory properties, amongst others, including antioxidant properties.

Ethanol extracts of sesame seeds were tested for antimicrobial activity against certain bacteria (Proteus mirabilis, Erwinia coli, Pseudomonas aeruginosa, Staphylococcus aureus, and Candida albicans). The anti-inflammatory and analgesic qualities of black sesame seeds have been confirmed.

Rose also possesses anti-inflammatory, analgesic, and astringent properties, as per Unani texts (Ghani, 2001). The antimicrobial activity of rose has been confirmed against P. aeruginosa, E. coli, Bacillus subtilis, S. aureus, Erwinia carotovora, and Chromobacterium violaceum strains in an experiment^​12​.

The authors concluded that the sesame rose treatment for uncomplicated PID is a cost-effective, safe and effective treatment for PID, and can be used as a substitute for drug treatment of female genital tract infections.

Certain other Unani (traditional South Asian) herbal medicines have been used successfully in pelvic infections^​13​, including:

• Solanum nigrum (Mako, black nightshade)
• Althaea officinalis (Tukhme Khatmi, marshmallow)
• Berberis aristate (Raswat Zard, Indian barberry)
• Achillea millefolium (Brinjasif, yarrow)
• Cichorium intybus (Kasni, chicory)
• Trigonella foenum-graecum (Methi, fenugreek)
• Rosa damascena Mill (Gule Surkh, rose)
• Plantago ovata (Isapghol, blond plantain, blond psyllium)
• Linum usitatissimum (Katan, flax, linseed)

These botanicals are pharmacologically antibacterial, analgesic, antipyretic and anti-inflammatory^​14​.

The PID pomegranate peel compound (punicalagin) experiment^​15​

An animal model demonstrated that phenolic compound derived from pomegranate peel, punicalagin, had an anti-inflammatory and antioxidant impact on pelvic inflammatory disease. The therapeutic group had PID caused by both E. coli and S. aureus.

In the three animal groups, one group had prophylactic (preventative) high dose punicalagin daily before being induced with PID, while the therapeutic group already had PID for one day before treatment with punicalagin began. Another group served as the PID controls without treatment.

In the PID groups, there were clear signs of inflammation and oxidative stress, with infiltration of neutrophils (immune white blood cells), raised levels of inflammatory cytokines, and markers of oxidative stress.

Treatment with punicalagin significantly decreased levels of IL-1β, catalase and lipid peroxidation in both the prophylactic and therapeutic groups when compared to PID controls. Punicalagin reduced the infiltration of leucocytes (white blood cells) into the uterus in both the active study groups when compared with the PID controls.

Fuke Qianjin Chinese medicine with antibiotics improves PID outcomes

There are several studies into Chinese herbal medicine, Fuke QuianJin, for pelvic inflammatory disease treatment, particularly when combined with conventional treatment of antibiotics^​16,17​.

A systematic review into Fuke QianJin for PID found that:

‘Fuke Qianjin tablet combined with conventional therapy showed better clinical efficacy in the treatment of acute pelvic inflammatory disease, chronic pelvic inflammatory disease, and endometritis. There were no obvious drug-related adverse reactions.

Fuke Qianjin tablet presented advantages in shortening the remission time of clinical symptoms, reducing the concentration of serum inflammatory factors, improving endometrial thickness, menstruation, and reducing relapse rate.‘

Acupuncture for PID pain

There is some evidence^​9,11​ that acupuncture can help ease the pain caused by PID, while other treatments are pursued. Acupuncture is not considered harmful.

Inflammatory diet and PID

There is a strong association between an inflammatory diet and the development of pelvic inflammatory disease^​6​. An anti-inflammatory diet modification may be a suitable supportive treatment for resolving PID.

Endometriosis and PID

Research^​2​ indicates that there is a significant association between PID and endometriosis diagnoses. In this particular study, over 30% of the women with endometriosis also had PID. Considering the bacterial theory of endometriosis^​3​, this lines up.

What causes infertility with PID?

PID can cause scar tissue to form on the uterus, fallopian tubes and ovaries, which can lead to blockages.

In some cases, a risk may be an ectopic pregnancy, where the embryo starts to grow in the fallopian tubes, instead of the uterus, which is dangerous. As the foetus grows, it will burst the fallopian tube, causing tissue to enter the abdominal cavity if not caught and removed early.

References^​1​

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