EXECUTIVE SUMMARY

According to a new report from the CDC, the prevalence of a self-reported lifetime diagnosis of pelvic inflammatory disease (PID) was 4.4% among sexually experienced reproductive-aged women, equating to 2.5 million prevalent PID cases in women ages 18-44 years nationwide.

  • Pelvic inflammatory disease is an often-symptomless infection of the reproductive tract that can cause infertility.
  • Women suffering from PID can present with many symptoms, from subtle to severe. Women and even clinicians may not recognize these signs if they are mild.

About 2.5 million American women have experienced pelvic inflammatory disease (PID), an often-symptomless infection of the reproductive tract that can cause infertility.1 According to a new report from the CDC, the prevalence of a self-reported lifetime PID diagnosis was 4.4% among sexually experienced reproductive-aged women, equating to 2.5 million prevalent PID cases in women ages 18-44 years nationwide. Prevalence of a self-reported lifetime PID diagnosis varied by sexual behaviors and sexual health history and differed by race/ethnicity in women without a prior sexually transmitted infection (STI) diagnosis, the analysis indicates.1

PID occurs when certain bacteria move from the vagina or cervix into reproductive organs. Many different microorganisms can cause PID, with Chlamydia trachomatis and Neisseria gonorrhoeae causing as many as half of these cases.2,3

What led researchers from the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention to study the subject of PID prevalence?

PID often is associated with STIs, says the study’s lead author, Kristen Kreisel, PhD, a CDC epidemiologist. With reported cases and rates of gonorrhea and chlamydia increasing in recent years, and because there is no single diagnostic test for PID, it is important to assess the burden of PID and specific factors that may increase the risk of PID for some women, she notes.

“Because chlamydia and gonorrhea are often asymptomatic and may go undiagnosed or untreated, screening of all sexually active women younger than 25 is critical for reducing the burden of disease and potential long-term consequences like PID,” Kreisel says.

Sleepwalking into infertility is a problem that presents in a number of ways, says Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta. Perhaps the most important is undiagnosed chlamydia infections that are damaging a young woman’s fallopian tubes, he says.

A 2014 analysis of national data indicated chlamydia prevalence at 1.7% among U.S. residents ages 14-39 years. However, among sexually active women 14-24 years of age, chlamydia prevalence was 4.7% overall and 13.5% among non-Hispanic blacks.4

Evaluate Evidence

To assess the burden of self-reported PID in a nationally representative sample, researchers used data from the 2013-2014 National Health and Nutrition Examination Survey (NHANES). Starting in 2013, NHANES female participants 18-44 years of age were asked about a lifetime history of PID diagnosis. Based on these data, the estimated prevalence of self-reported lifetime PID was 4.4% in sexually experienced women of reproductive age (18-44 years).

The prevalence of self-reported lifetime PID was highest in women at increased risk, such as women reporting a previous STI diagnosis. When stratified by race/ethnicity and having a previous STI diagnosis, non-Hispanic black (black) and non-Hispanic white (white) women reporting a previous STI diagnosis had nearly equal self-reported lifetime PID prevalence (10.0% vs. 10.3%). However, the lifetime prevalence of PID among black women was 2.2 times higher than among white women if no previous STI was diagnosed (6.0% vs. 2.7%).

Researchers concluded these findings suggest that PID is prevalent and associated with previous STI diagnoses. Therefore, it is important for clinicians to screen female patients for chlamydia and gonorrhea to reduce the incidence of PID.1

“Given the potential for asymptomatic infections to lead to PID and the costs associated with treatment, it is important for clinicians to adhere to U.S. Preventive Services Task Force guidelines5 for chlamydia and gonorrhea screening in an effort to decrease the PID burden in sexually experienced women of reproductive age nationwide,” the researchers concluded.

Check Symptoms

Women suffering from PID can present with symptoms that could be characterized as mild all the way to severe and everything in between. Both patients and clinicians might not recognize these signs if they are mild. Because PID signs can exhibit nonspecifically, clinicians should consider urinary and gastrointestinal tract diseases as well other reproductive tract maladies in sexually active women complaining of pain in the lower abdomen. However, clinicians must exclude pregnancy, including ectopic pregnancy, because PID has been known to happen concurrently with pregnancy.

So what should clinicians check? The CDC says symptoms include, but are not limited to:

  • mild pelvic pain;
  • increased vaginal discharge;
  • irregular menstrual bleeding;
  • pain with intercourse;
  • painful and frequent urination;
  • pelvic organ tenderness;
  • uterine tenderness;
  • adnexal tenderness; and
  • inflammation.6

According to the CDC, clinicians should begin presumptive treatment for PID in sexually active young women and other women at risk for STIs if those patients complain about pelvic or lower abdominal pain, if the clinician cannot identify any other cause for the illness other than PID, and if the clinician discovers one or more of the following minimum clinical criteria on a pelvic exam: cervical motion tenderness or uterine tenderness or adnexal tenderness.

The CDC warns that the requirement that all three minimum criteria be present before starting empiric treatment could result in insufficient sensitivity for the diagnosis of PID. After deciding about treatment, clinicians should consider the patient’s risk for STIs.

There are several other criteria clinicians can use to boost the specificity of the minimum clinical criteria and support a provider’s PID diagnosis:

  • Oral temperature greater than 101°F;
  • Abnormal cervical mucopurulent discharge or cervical friability;
  • Presence of abundant numbers of WBC on saline microscopy of vaginal fluid;
  • Elevated erythrocyte sedimentation rate;
  • Elevated C-reactive protein; and
  • Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.6

How to Treat?

How can clinicians treat PID once it is diagnosed? The CDC says broad-spectrum antibiotics will take care of likely pathogens, while other types of antibiotics can cure PID. However, the CDC warns that antibiotic treatment won’t reverse any scarring that infection already has caused. This finding emphasizes the importance of immediate care if a woman experiences pelvic pain or other symptoms of PID. Timely antibiotic treatment could prevent severe damage to reproductive organs.

Refer to recommended treatment regimens in the 2015 STD Treatment Guidelines.7 (Check the guidance online at: http://bit.ly/2k86xqp.) Counsel patients that although symptoms may alleviate before an infection is cured, patients should complete the prescribed course of medicine. Also, the patient’s sex partner(s) should receive treatment to reduce reinfection risks, even if the partner has yet to report any symptoms. Sex partners may not complain of symptoms, but the CDC warns that the partners still may be infected with organisms that can lead to PID.

REFERENCES

  1. Kreisel K, Torrone E, Bernstein K, et al. Prevalence of pelvic inflammatory disease in sexually experienced women of reproductive age – United States, 2013-2014. MMWR Morb Mortal Wkly Rep 2017;66:80-83.
  2. Haggerty CL, Ness RB. Epidemiology, pathogenesis and treatment of pelvic inflammatory disease. Expert Rev Anti Infect Ther 2006;4:235-247.
  3. 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;186:929-937.
  4. Torrone E, Papp J, Weinstock H; Centers for Disease Control and Prevention. Prevalence of Chlamydia trachomatis genital infection among persons aged 14-39 years — United States, 2007-2012. MMWR Morb Mortal Wkly Rep 2014;63:834-838.
  5. LeFevre ML; U.S. Preventive Services Task Force. Screening for chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014;161:902-910.
  6. Centers for Disease Control and Prevention. Pelvic Inflammatory Disease. Fact sheet. Available at: http://bit.ly/2l303ts. Accessed Feb. 20, 2017.
  7. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-3):1-137.