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Overview

elvic inflammatory disease (PID) is a general term that refers to infection and inflammation of the upper genital tract in women. It can affect the uterus (womb), fallopian tubes (tubes that carry eggs from the ovaries to the uterus), ovaries, and other organs related to reproduction. The scarring that results on these organs can lead to infertility, tubal (ectopic) pregnancy, chronic pelvic pain, abscesses (sores containing pus), and other serious problems. PID is the most common preventable cause of infertility in the United States.

Women at greater risk for PID include those at risk for sexually transmitted infections (STIs) and those with a prior episode of PID. Sexually active women under age 25 are at risk as well because the cervix (opening to the uterus) of teens and young women has greater susceptibility to STIs. This may be because the cervix of teenage girls and young women is not fully matured, increasing their risk for STIs linked to PID.

Other potential risk factors include douching, which women should avoid. In some women, using an intrauterine device (IUD) to prevent pregnancy can also cause PID. Rarely, PID results from gynecological procedures or surgeries.

In the United States, more than 1 million women seek treatment for acute PID each year, according to the Centers for Disease Control and Prevention (CDC). A similar or greater number of women may have PID and not know it. PID is more common among teenage than adult women. It is also more common among African-American and Hispanic women.

Every year, more than 100,000 women become infertile and more than 150 women die from PID or its complications..

Cause

PID is caused by bacteria that cause sexually transmitted infections such as chlamydia or gonorrhea.

Symptoms

• Fever
• Vaginal discharge that may have an odor
• Painful intercourse
• Painful urination
• Irregular menstrual bleeding
• Pain in the upper right abdomen (rare)

Sometimes PID comes on suddenly with extreme pain and fever, especially if it is caused by gonorrhea.

Diagnosis

PID can be difficult for your health care provider to diagnose because symptoms can be subtle and mild and similar to those of some other diseases. If you think you might have PID, you should get medical care promptly because early treatment can limit long-term complications such as infertility and chronic pelvic pain.

If you have symptoms such as lower abdominal pain, your health care provider will perform a physical exam, including a pelvic (internal) exam, to find out the nature and location of the pain. Your health care provider also will check for

• Abnormal vaginal or cervical discharge
• Masses near your ovaries and tubes
• Tenderness or pain of your abdomen, cervix, uterus, and ovaries

Health experts have found that about 70 percent and 50 percent of chlamydial and gonococcal infections, respectively, are asymptomatic (without symptoms) in women. These infections were found first through screening. You should get regular laboratory tests for chlamydia, gonorrhea, urinary tract infection, and if appropriate, pregnancy. Your health care provider may suggest these tests as part of a routine annual exam as well as tests for HIV infection and syphilis.

If necessary, your health care provider may do other tests such as an ultrasound (sonogram), endometrial (uterine) biopsy, or laparoscopy to distinguish between PID and other serious problems that can mimic PID.

Laparoscopy is a surgical procedure in which a tube is inserted through a small incision near your navel. This allows your health care provider to view the internal abdominal and pelvic organs and to take specimens to examine in the laboratory.

Treatment

According to CDC, health care providers should start treating sexually active young women and other women at risk for STIs if they have motion tenderness of the uterus, ovaries, fallopian tubes, or cervix. Without adequate treatment, 20 to 40 percent of women with chlamydia and 10 to 40 percent of women with gonorrhea may develop PID.

Many different bacteria may cause an episode of PID. Therefore, your health care provider will prescribe antibiotics (generally two at once, by injection or by mouth) that are effective against a wide range of bacteria, including those causing chlamydia and gonorrhea. You should begin treatment as soon as your health care provider diagnoses PID because complications of the disease may be prevented with taking antibiotics immediately.

Women who douche may have higher risk of developing PID. Douching can change the vaginal flora (organisms that live in the vagina) and can force bacteria from the vagina into the upper reproductive organs.

Even if your symptoms go away, you should finish taking all of the medicine. You also should return to your health care provider 2 to 3 days after beginning the medicine to be sure the antibiotics are working.

Your health care provider may recommend going into the hospital to treat your PID if you

• Are severely ill
• Are pregnant
• Do not respond to or cannot take oral medicine
• Need intravenous (in the vein) antibiotics
• Have an abscess (swelling) in your fallopian tube or ovary

If your symptoms continue or if an abscess does not go away, you may need surgery.

Complications of PID such as chronic pelvic pain and scarring are difficult to treat, but sometimes they improve with surgery.

Many sex partners may be infected with bacteria that cause PID and do not know it because they do not have symptoms. To protect yourself from being re-infected with bacteria that cause PID, you should discuss this with your health care provider.

Prevention

The surest way to avoid getting or transmitting sexually transmitted infections (STIs) is to abstain from sex or to be in a long-term, mutually monogamous relationship with a partner who has been tested and isn’t infected. Condoms, when used consistently and correctly, can reduce your risk of getting chlamydia and gonorrhea.

In addition, you can protect yourself from PID by getting treated quickly if you do get an STI.

The most common preventable cause of PID is an untreated STI, mainly chlamydia or gonorrhea. CDC recommends yearly chlamydia testing of all sexually active women age 25 or younger and of older women with risk factors for chlamydia (those who have a new sex partner or many sex partners). If you have had chlamydia, you also should be re-tested several months after completing treatment so you can be re-treated, if necessary.

Complications

Prompt and appropriate treatment can help prevent complications of PID. Without treatment, PID can cause permanent damage to the female reproductive organs. Infection-causing bacteria can silently invade the fallopian tubes, causing normal tissue to turn into scar tissue. This scar tissue blocks or interrupts the normal movement of eggs into the uterus.

If your fallopian tubes are totally blocked by scar tissue, sperm cannot fertilize an egg and you become infertile. Infertility also can occur if the fallopian tubes are partially blocked or even slightly damaged. About one in five women with PID becomes infertile.

In addition, a partially blocked or slightly damaged fallopian tube may cause a fertilized egg to remain in the fallopian tube. If this fertilized egg begins to grow in the tube as if it were in the uterus, it is called an ectopic or tubal pregnancy. An ectopic pregnancy can rupture the fallopian tube, causing severe pain, internal bleeding, and even death.

Scarring in the fallopian tubes and other pelvic organs can also cause chronic pelvic pain (pain lasting for months or even years). You are more likely to suffer infertility (20 percent of women), ectopic pregnancy (9 percent), or chronic pelvic pain (18 percent) if you have repeated episodes of PID.

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Overview

Human papillomavirus

Human papillomavirus (HPV) is one of the most common causes of sexually transmitted infection (STI) in the world. Health experts estimate there are more cases of genital HPV infection than any other STI in the United States. According to the Centers for Disease Control and Prevention (CDC), approximately 6.2 million new cases of sexually transmitted HPV infections are reported every year. At least 20 million people in this country are already infected.

Genital warts

Genital warts (sometimes called condylomata acuminata or venereal warts) are the most easily recognized sign of genital HPV infection. Many people, however, have a genital HPV infection without genital warts.

Genital warts are soft, moist, or flesh colored and appear in the genital area within weeks or months after infection. They sometimes appear in clusters that resemble cauliflower-like bumps, and are either raised or flat, small or large. Genital warts can show up in women on the vulva and cervix, and inside and surrounding the vagina and anus. In men, genital warts can appear on the scrotum or penis. There are cases where genital warts have been found on the thigh and groin.

Cause

More than 100 different types of HPV exist, most of which are harmless. About 30 types are spread through sexual contact and are classified as either low risk or high risk.

Some types of HPV cause genital warts–single or multiple bumps that appear in the genital areas of men and women including the vagina, cervix, vulva (area outside of the vagina), penis, and rectum. These are considered low-risk types.

High-risk types of HPV may cause abnormal Pap smear results. They could lead to cancers of the cervix, vulva, vagina, anus, or penis.

Transmission

Genital warts are very contagious. You can get them during oral, vaginal, or anal sex with an infected partner. You can also get them by skin-to-skin contact during vaginal, anal, or (rarely) oral sex with someone who is infected. About two-thirds of people who have sexual contact with a partner with genital warts will develop warts, usually within 3 months of contact.

If you are infected but have no symptoms, you can still spread HPV to your sexual partner and/or develop complications from the virus.

Symptoms

In women, genital warts occur on the outside and inside of the vagina, on the opening to the uterus (cervix), or around the anus.

In men, genital warts are less common. If present, they usually are seen on the tip of the penis. They also may be found on the shaft of the penis, on the scrotum, or around the anus.

Rarely, genital warts also can develop in your mouth or throat if you have oral sex with an infected person.

Like many STIs, genital HPV infections often do not have signs and symptoms that you can see or feel. One study sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) reported that almost half of women infected with HPV had no obvious symptoms.

If you are infected but have no symptoms, you can still spread HPV to your sexual partner and/or develop complications from the virus.

Diagnosis

Your health care provider usually diagnoses genital warts by seeing them.

If you are a woman with genital warts, you also should be examined for possible HPV infection of the cervix. Your health care provider can diagnose HPV infection based on results from an abnormal Pap smear, a primary cancer-screening tool for cervical cancer or pre-cancerous changes of the cervix. In some cases, a health care provider will take a small piece of tissue from the cervix and examine it under the microscope.

Another test to diagnose HPV infection detects HPV DNA, which may indicate possible infection.

Your provider may be able to identify some otherwise invisible warts in your genital tissue by applying vinegar (acetic acid) to areas of your body that might be infected. This solution causes infected areas to whiten, which makes them more visible.

Treatment

There are treatments for genital warts, though the warts often disappear even without treatment. There is no way to predict whether the warts will grow or disappear. Therefore, if you suspect you have genital warts, you should be examined and treated, if necessary.

Depending on factors such as the size and location of your genital warts, your health care provider will offer you one of several ways to treat them.

• Imiquimod cream
• 20 percent podophyllin antimitotic solution
• 0.5 percent podofilox solution
• 5 percent 5-fluorouracil cream
• Trichloroacetic acid (TCA)

If you are pregnant, you should not use podophyllin or podofilox because they are absorbed by your skin and may cause birth defects in your baby. In addition, you should not use 5-fluorouracil cream if you are pregnant.

If you have small warts, your health care provider can remove them by one of three methods.

• Freezing (cryosurgery)
• Burning (electrocautery)
• Laser treatment

If you have large warts that have not responded to other treatment, you may have to have surgery to remove them.

Some health care providers inject the antiviral drug alpha interferon directly into warts that have returned after removal by traditional means. The drug is expensive, however, and does not reduce the rate that the genital warts return.

Although treatments can get rid of the warts, none get rid of the virus. Because the virus is still present in your body, warts often come back after treatment.

Prevention

The best way to prevent getting an HPV infection is to avoid direct contact with the virus, which is transmitted by skin-to-skin contact.  If you or your sexual partner has warts that can be seen in the genital area, you should avoid any skin-to-skin and sexual contact until the warts are treated.

Recently, the Food and and Drug Administration (FDA) approved a vaccine called Gardasil. Gardasil is highly effective in preventing persistent infection with HPV types 16 and 18, two “high-risk” HPVs that cause most (70 percent) of cervical cancers, and types 6 and 11, which cause virtually all (90 percent) of genital warts.

Gardasil has not been proven to provide complete protection against persistent infection with other HPV types, some of which also can cause cervical canter. Therefore, about 30 percent of cervical cancers and 10 percent of genital warts will not be prevented by the current vaccine. In addition, Gardasil does not prevent other STIs, nor does it treat HPV infection or cervical cancer.

Historically, research studies have not confirmed that male latex condoms prevent transmission of HPV. Recent studies, however, demonstrate that consistent condom use by male partners suggests strong protection against low- and high-risk types of HPV infection in women.

Unfortunately, many people who don’t have symptoms don’t know that they can spread the virus to an uninfected partner.

Complications

Cancer

Some types of HPV can cause cervical cancer. Other types are associated with vulvar cancer, anal cancer, oral cancer, and cancer of the penis (a rare cancer).

Most HPV infections do not progress to cervical cancer. If you are a woman with abnormal cervical cells, a Pap smear will detect them. If you have abnormal cervical cells, it is particularly important for you to have regular pelvic exams and Pap smears so you can be treated early, if necessary.

Pregnancy and Childbirth

Genital warts may cause a number of problems during pregnancy. Because genital warts can multiply and become brittle, your health care provider will discuss options for their removal, if necessary.

Genital warts also may be removed to ensure a safe and healthy delivery of the newborn. Sometimes they get larger during pregnancy, making it difficult to urinate if the warts are in the urinary tract. If the warts are in the vagina, they can make the vagina less elastic and cause obstruction during delivery.

Rarely, infants born to women with genital warts develop warts in their throats (respiratory papillomatosis). Although uncommon, it is a potentially life-threatening condition for the child, requiring frequent laser surgery to prevent blocking of the breathing passages. Research on the use of interferon therapy with laser surgery indicates that this drug may show promise in slowing the course of the disease.

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