Pelvic inflammatory disease (PID) is a complication of prevalent sexually transmitted diseases. Many women with this condition will have long-term consequences, including chronic pelvic pain (about 1 in 5), decreased primary fertility (about 12% with one infection, increasing to 75% after 3 or more infections), and a 6-fold increased risk of future ectopic pregnancy due to scarring of the Fallopian tubes. There is also associated difficulty with pregnancy implantation, even with IVF treatments, and a risk of severe abscesses in the area of the Fallopian tubes and ovaries. The longer this condition goes on without being treated, the more likely irreversible damage will occur.

While sometimes PID can cause severe pain, fever, and abnormal vaginal discharge in the acute time period, it can also be mild enough to pass for other things and go unnoticed for sometimes years.

As most often, the organisms are sexually transmitted, practicing safer sex, including regular STI testing for both partners and using barrier methods, does reduce the risk.

[signup]

What is Pelvic Inflammatory Disease (PID)?

Pelvic inflammatory disease (PID) is an infection and inflammation in the female pelvic region. It may be nearly imperceptible or cause serious pain, particularly during sex. No matter the severity of the symptoms, it is always a serious infection.

It starts when an infection travels up the female genital tract from the vagina through the cervix to the upper genital structures, including the uterus, ovaries, and Fallopian tubes. If not treated, this infection can spread through the pelvis and cause more widespread inflammation. In rare cases, it can even spread to the liver. If untreated for a prolonged period of time, this will lead to scarring, which can cause chronic pelvic pain as well as an increased risk of difficulty conceiving, infertility, and ectopic pregnancy.

By far, the most common organisms to cause PID are chlamydia and/or gonorrhea. It also appears that multiple organisms are involved in nearly half of the cases.  

Pelvic Inflammatory Disease (PID) Symptoms

One of the reasons STI testing is particularly important in at-risk individuals is that PID may develop with few or no noticeable symptoms.

Due to the high risk of sequelae, empiric treatment is recommended based on presentation. The symptoms triggering empiric treatment according to the current CDC guidelines are:

• Patients at risk for an STD (female or AFAB age 15-25, especially if they have multiple sexual partners and/or unprotected sex)
• Pelvic or lower abdominal pain with no other identifiable cause
• A pelvic exam showing at least one of the following:
• Tenderness with cervical motion
• Uterine tenderness
• Adnexal (ovary) tenderness

The pain typically lasts less than seven days, and symptoms tend to resolve within 48-72 hours of starting treatment.

Other symptoms that may be present include:

• Fever, especially with an oral temperature over 101 degrees F
• Cervical or vaginal discharge that is not normal and may appear consistent with infection (yellow or green, or smelly)
• Nausea or vomiting
• Pain during sex felt deep in the pelvis
• Irregular periods
• Burning sensation when peeing

What Causes Pelvic Inflammatory Disease (PID)?

Most often, pelvic inflammatory disease is the result of a sexually transmitted organism causing an infection that ascends the female reproductive tract from the vagina through the cervix and into the uterus, fallopian tubes, and ovaries. This infection then triggers inflammation and scarring of these organs if not promptly treated.

The individuals most at risk from PID are younger women, typically 15-25 years old, especially those who are sexually active with multiple partners or with partners who have multiple partners. Having unprotected sex is also a significant aspect of risk, as it increases the chances of getting a sexually transmitted infection.

The most common organisms to cause PID are Chlamydia and Gonorrhea. Some more recently emerging organisms like Mycoplasma genitalium may also cause PID and, in some reports, cause a more mild case that may be more likely to go unnoticed. Importantly, infections by Mycoplasma genitalium may not be adequately treated by current protocols. Additional organisms that may be involved in PID include Gardnerella vaginalis (bacteria that causes BV), Haemophilus influenza, and species of Bacteroids and Peptococcus.

Much less commonly, PID can occur from situations that introduce normal vaginal bacteria into the upper genital tract, including childbirth, miscarriage, abortion, pelvic surgery, including for ectopic pregnancy, and getting an IUD. It appears IUD use is associated with a higher risk in women over 35.

Diets that are low in the micronutrients vitamins A, C, D, E, B-Carotene, folate, and calcium or high in high-glycemic carbohydrates have been associated with less resilient vaginal microbiomes and greater susceptibility to vaginal dysbiosis and infections, which could lead to PID.  

Functional Medicine Labs to Test for Root Cause of Pelvic Inflammatory Disease (PID)

A pregnancy test should always be completed in the first round of testing to diagnose possible Pelvic Inflammatory Disease. The symptoms of PID and certain pregnancy emergencies, such as ectopic pregnancy, can overlap, and ectopic pregnancy can quickly turn into a medical emergency.

The next consideration would be to test by an endocervical swab collected during a speculum vaginal exam for the most likely organisms to cause PID. If it is not possible to perform a speculum exam, a vaginal swab may be used instead. The key organisms are Chlamydia trachomatis, Nisserria gonorrhoeae, and Mycoplasma genitalium. The preferred test, if possible, would be a nucleic acid amplification (NAAT) test. However, it is also useful to collect three swabs so that in addition to one for the NAAT, there is one for direct examination under a microscope with gram stain and MGG stain, as well as one that can be sent for culture with antibiotic susceptibility testing. While positive NAAT results show a sexually transmitted infection (STI) agent causing PID, a negative result does not mean it is not present.

In addition, depending on symptoms, testing for T. Vaginalis, HIV, and syphilis may also be considered. The cervical secretions may be examined under the microscope for leukocytes which would be present to fight the infection. A urine sample may also be tested for leukocyte esterase and white blood cells.

Additional blood testing may show abnormally high levels of white blood cells (on a CBC test), which are fighting the infection, as well as elevated markers of generalized inflammation, including erythrocyte sedimentation rate (ESR) (>40 mm/h) and C-reactive protein (CRP) (>60 mg/L).

If labs alone are not adequately clarifying the situation, imaging, particularly ultrasound, may be used to see the reproductive organs and pelvic spaces. In some cases, an endometrial biopsy will be taken, or direct visualization will be conducted by laparoscopy.

If someone is experiencing repeated episodes of PID, additional functional testing of factors influencing the immune system, including micronutrient status, diabetes, and stress hormone levels, may be worth considering.

Conventional Treatment for Pelvic Inflammatory Disease (PID)

The main objectives of treatment for pelvic inflammatory disease (PID) are to relieve the acute symptoms, clear the infection, and minimize the risk of long-term consequences. It is also desirable to reduce the risk of speed to new sexual partners or re-infection by an untreated partner. In many states, this leads to unique guidelines for the treatment of partners.  

As rapid diagnosis and treatment seem to be key to avoiding long-term impairments to fertility, the CDC recommendation is that treatment is started based on symptoms in an at-risk individual rather than waiting for additional testing, preferring over treatment to under treatment. Symptoms that trigger antibiotics would include lower abdominal pain, tenderness in the area of the ovaries, and pain with the movement of the cervix.

Broad-spectrum antibiotics are used that cover all of the common organisms that cause PID, most especially chlamydia and gonorrhea. Specific antibiotics used should be adjusted based on local patterns of resistance. The CDC has created guidelines for antibiotic regimes for PID. The oral protocols involve an injection of ceftriaxone (500mg or 1g muscular injection), cefoxitin (2g muscular injection and 1g by mouth), or another third-generation cephalosporin followed by 14 days of Doxycycline (100 mg twice daily) and metronidazole (500 mg twice daily).

Antibiotic therapy alone may adequately treat many cases. In some of the remaining cases, when surgery may be needed, the maintenance of fertility is protected more than it used to be. Typically, the infection is merely drained with adhesions being cleared, and if an ovary must be removed, the other will be left intact if possible. If a tubo-ovarian abscess has formed, rapid rather than delayed surgical treatment may significantly protect future fertility.

Functional Medicine Treatment for Pelvic Inflammatory Disease (PID)

As the bacterial infection is a core component of the problem with Pelvic Inflammatory Disease (PID), identifying and treating the infection with appropriate antibiotics should be the first and most urgent priority.

In considering the non-STI causes of PID, it would also be advisable to use extra caution about any possible exposure to infection during the first month after any disruption to the cervix, including IUD insertion, miscarriage, or surgery.

Microflora in both the gut and vagina are important for resilience to infection and can be positively affected by a healthy lifestyle, good diet, ample sleep, stress management, as well as situational supplementation with prebiotics and probiotics. This may help to reduce the risk of recurrence as well as reduce inflammation.

During treatment, inflammation can be addressed as it is a core part of how adhesions form. This could involve diet, healthy lifestyle, stress management, and possible supplementation with anti-inflammatory nutrients (Omega-3 fatty acids) and/or herbs (curcumin, ginger)

If the problem seems to be recurring, environmental, nutritional, and allergy factors that may be decreasing immune function and increasing overall inflammation may be worth evaluating and addressing.

Nutrition

When dealing with a condition causing infection and excessive inflammation, nutrition may play some role in optimal healing. Key considerations would be ensuring one is consuming adequate macro and micronutrients for optimal immune function. This is generally going to be pushing one towards a plant-based, whole foods diet with ample colorful fruits and vegetables. A focus on anti-inflammatory functional foods such as omega-3 fatty acids and turmeric/ginger in absorbable preparations may help minimize excess inflammation during healing.

Any identified or suspected food allergens or sensitivities should be avoided to avoid triggering additional inflammation. Highly processed foods and added sugar should also be minimized.

Prebiotic foods, such as those containing soluble fiber and fermented foods with active cultures, may help maintain a healthy vaginal flora, strengthening resilience against infection as well as re-populating after necessary antibiotic treatment.

Complementary and Alternative Medicine

Given the consequences of not treating, PID is one situation where antibiotics are often used empirically with a lower threshold than in many other conditions. This is also a reason that antimicrobial herbs should not be considered a primary treatment for PID if antibiotics are available. It may be helpful to supplement with pre and probiotics to help in re-establishing a healthy gut flora during and after antibiotic treatment.  

However, a 2023 study showed that a group of women with uncomplicated PID treated with an herbal pessary of linseed, psyllium, and honey did better than those receiving standard antibiotics.  

Other complementary modalities may provide symptomatic relief and/or reduce stress and thus optimize immune function, potentially decrease perception of pain, and enhance immune system response rate.

Chinese herbal medicine may also help to increase fertility when it is low after PID.

Summary

Pelvic inflammatory disease is a high consequence illness that affects primarily young women. Conventional and Functional approaches converge around the importance of identifying and treating the infection, preferring to err on the side of more aggressive antibiotic use in this particular situation. In addition, adding pre and probiotics, potentially also probiotic vaginal suppositories, may help with re-establishing a resilient bacterial flora.  

Particularly in recurrent or prolonged cases, it may be helpful to also consider lifestyle factors, such as diet, micronutrient status, and stress levels.

Prevention can not be guaranteed, but risk factors can be minimized by using safer sex methods, including regular STI testing, and using barriers, especially with partners with less known history or numerous concurrent partners.