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 to reproductive organs can occur 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 an 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 evidence⁴ 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 not⁵.

Eating an inflammatory diet was also strongly associated with PID⁶.

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 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 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 directly affect 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 sensitisation⁷. 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 precisely a ‘disease’, but rather a condition of inflammation in the pelvis that can have multiple causes. Those between the ages of 15 and 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 important. 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 study⁸ of people who needed surgery for acute PID, about 35% had a tubo-ovarian abscess and around 59% had a pathogen identified. Of those with a positive culture, most infections involved a single organism, and E. coli was the most common, found in roughly 41%. 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 the microbial infection, and to prevent further spread. Prompt antibiotics are the standard of care and should not be delayed – PID is a serious infection, and leaving it untreated risks infertility, ectopic pregnancy, abscesses and sepsis. Some botanicals^9,10 and complementary treatments^9,11 show promise as supportive, adjunctive options alongside antibiotics, and research into them is growing, but the current evidence does not support using them in place of antibiotics.

Antibiotics for the 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 includes¹:

• 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 therapy¹:

• 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 trialled for PID with some promising early results^9,10, though the studies are mostly small or preliminary and are best seen as potential add-ons to antibiotic treatment rather than replacements for it.

In particular, one small double-blind randomised trial¹⁰ in uncomplicated PID (60 women, half given the herbal oils and half given doxycycline plus metronidazole) found the herbal preparation produced a similar improvement in symptom scores – pain and tenderness – over 15 days. It measured symptom relief rather than confirmed microbiological cure, and with only 60 participants it is far too small to conclude the oils truly match antibiotics.

Black sesame seeds have natural antibacterial effects against Staphylococcus and Streptococcus species, as well as antifungal, antiviral, anti-inflammatory, and 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 experiment¹².

The trial’s authors suggested the sesame–rose preparation could be a cost-effective option, and even a possible substitute for standard drugs in uncomplicated cases – but this is one small study. Until it is repeated in larger trials, antibiotics remain the treatment to rely on for PID.

Certain other Unani (traditional South Asian) herbal medicines have been used successfully in pelvic infections¹³, 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-inflammatory¹⁴.

The PID pomegranate peel compound (punicalagin) experiment¹⁵

An animal model demonstrated that a 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, including neutrophil infiltration (immune white blood cells), elevated 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 leucocyte (white blood cell) infiltration into the uterus in both active study groups compared with 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, used alongside antibiotics rather than instead of them. The trials are small and of low quality, so treat it as a possible add-on for pain relief. Acupuncture is not considered harmful.

Inflammatory diet and PID

There is a strong association between an inflammatory diet and the development of pelvic inflammatory disease⁶. An anti-inflammatory diet modification may be a suitable supportive treatment for resolving PID.

Endometriosis and PID

Research² 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 endometriosis³, 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.

Frequently asked questions

What are the warning signs of pelvic inflammatory disease?

Lower abdominal or pelvic pain is the main one, often with unusual or smelly discharge, pain during sex, bleeding between periods, fever or burning when you wee. Symptoms can be mild, so do not wait them out – PID needs prompt treatment to protect your fertility.

Can PID be treated without antibiotics?

No. Antibiotics are the standard treatment and should be started promptly – delaying them risks scarring, infertility, ectopic pregnancy and abscesses. Some botanicals and acupuncture are being researched as supportive add-ons, but the evidence does not support using them instead of antibiotics.

Can pelvic inflammatory disease make you infertile?

It can. PID can leave scar tissue on the fallopian tubes, uterus and ovaries, which may block the tubes and cause infertility or a dangerous ectopic pregnancy. The risk rises with repeated or untreated infections, which is why early treatment matters so much.

Do herbal or Chinese medicine treatments cure PID?

There are some promising early studies – a small trial of sesame and rose oil, and reviews of Fuke Qianjin used alongside antibiotics – but they are mostly small, preliminary, or tested as add-ons to antibiotics. None of them replace standard antibiotic treatment for PID.

This article is general information about PID, not medical advice. PID is a serious infection that needs prompt medical assessment and antibiotics – if you have pelvic pain, unusual discharge, fever or pain during sex, please see a doctor or sexual health clinic quickly. Left untreated, PID can permanently affect your fertility, so please do not try to manage it with home or herbal remedies alone.

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