Pelvic inflammatory disease, also known as pelvic infection or PID, is an infection of a woman's internal reproductive organs: the uterus, fallopian tubes and ovaries. It almost always starts with bacteria from the vagina and cervix that travel upward. It mainly affects sexually active women under 25, and its importance lies in its consequences: if it is not treated quickly, it can leave permanent damage to the fallopian tubes.
Causes of pelvic inflammatory disease
In most cases, sexually transmitted bacteria are responsible, and chlamydia and gonorrhea are the most common culprits, while Mycoplasma genitalium and bacteria from the normal vaginal flora also play a role, especially when there is coexisting bacterial vaginitis. In many patients no specific organism is identified.
Less often, the infection reaches the pelvis from a neighboring organ, such as the appendix, or follows a procedure inside the uterus.
Which women are at higher risk
- Age under 25 and being sexually active.
- A new partner or multiple partners, sex without a condom.
- A previous episode of pelvic inflammatory disease or a sexually transmitted infection.
- Recent insertion of an intrauterine device (IUD). The risk is small and limited to the first three weeks.
- A recent uterine procedure, such as curettage or hysteroscopy.
- Vaginal douching, which disrupts the normal flora.
Symptoms
The picture ranges from almost unnoticeable to severe. The most common signs:
- lower abdominal pain, usually on both sides, which may radiate to the lower back,
- vaginal discharge with a change in color or odor,
- deep pain during intercourse,
- bleeding between periods or bleeding after intercourse,
- burning or pain when urinating,
- fever, chills, nausea in more severe forms.
Many women have only mild, dull discomfort. That does not mean the infection is harmless.
When you need urgent assessment
Severe abdominal pain, fever above 38.5°C, vomiting or feeling faint require immediate examination. The same applies if there is any chance of pregnancy, because we must rule out an ectopic pregnancy.
How the diagnosis is made
No single test confirms the disease. The diagnosis is mainly clinical and relies on a combination of history and findings:
- Gynecological examination: tenderness when the cervix is moved, in the uterus or in the adnexa.
- Vaginal and cervical swabs for chlamydia, gonorrhea and other bacteria.
- Pregnancy test, always.
- Blood tests: white blood cell count, CRP.
- Transvaginal ultrasound, to check for a hydrosalpinx or an abscess.
- Laparoscopy in uncertain cases or when treatment is not working.
Because delay is costly, treatment starts on the basis of clinical suspicion, without waiting for culture results.
Treatment
A combination of antibiotics covering all likely bacteria is given, usually for 14 days, together with pain relievers. Your doctor chooses the exact regimen. Four things matter:
- Finish the full course, even if you feel well by the third day.
- Follow-up in 48 to 72 hours. If there is no improvement, the treatment is changed.
- Your partner is examined and treated, even if he has no symptoms.
- Avoid sex until you have both finished treatment.
Hospital admission with intravenous antibiotics is needed in severe cases, in pregnancy, when there is a tubo-ovarian abscess or when oral treatment is not tolerated. An abscess that does not resolve may need drainage or laparoscopic treatment.
Complications: why we never leave it untreated
The inflammation leaves scars and adhesions in and around the fallopian tubes. The consequences often appear years later:
- Tubal factor infertility. The risk increases with each episode. If the tubes are blocked, the solution is usually laparoscopic tubal surgery or IVF.
- Ectopic pregnancy, because the fertilized egg has difficulty passing through a damaged tube.
- Chronic pelvic pain, caused by adhesions.
- Hydrosalpinx and tubo-ovarian abscess.
After pelvic inflammatory disease, tubal patency is checked with hysterosalpingography (HSG).
Prevention
- A condom every time with a new or non-steady partner.
- Chlamydia testing once a year for women under 25 and after every change of partner.
- Prompt treatment of any cervicitis or vaginitis.
- No vaginal douching.
- A regular annual gynecological check-up.
Pelvic inflammatory disease or something else? Conditions that look similar
Lower abdominal pain has many causes, and some of them need completely different treatment. That is why, before reaching a conclusion, the doctor considers and rules out:
- Ectopic pregnancy: pain usually on one side, a late or irregular period, a positive pregnancy test. It is an emergency.
- Appendicitis: the pain often starts around the navel and moves to the lower right side, with loss of appetite and nausea.
- Ovarian cyst torsion or rupture: sudden, severe pain on one side. The ultrasound shows the ovarian cyst.
- Endometriosis: pain that follows the cycle, painful periods, pain during intercourse, usually without fever.
- Pyelonephritis or cystitis: burning when urinating, lower back pain, abnormal urinalysis findings.
Telling them apart is not always easy, and sometimes repeat tests within a few hours or a laparoscopy are needed to reach the correct diagnosis.
When the pain moves up to the right side: Fitz-Hugh-Curtis syndrome
In a small percentage of women with pelvic inflammatory disease, the infection spreads to the peritoneum around the liver. Thin adhesions form between the liver and the diaphragm. The result is pain under the right ribs that gets worse with deep breathing or coughing and may radiate to the right shoulder.
This picture is easily confused with cholecystitis. If a young, sexually active woman has pain in the right upper abdomen with a normal gallbladder ultrasound, testing for chlamydia and gonorrhea is essential. The treatment is the same as for pelvic inflammatory disease.
The first days of treatment: a practical guide
- What to expect: pain and fever should improve within 48 to 72 hours. If not, contact your doctor right away.
- Rest: for the first few days, limit strenuous physical activity. The pain relievers you have been recommended help and allow you to sleep.
- Side effects: nausea, diarrhea or a metallic taste are common and usually mild. Take the pills with food, unless you have been told otherwise.
- Alcohol: if your treatment includes metronidazole, avoid alcohol completely during treatment and for 48 hours afterward.
- Doxycycline: take it with a large glass of water, while upright, not just before bed. It increases the skin's sensitivity to the sun.
- Candida: antibiotics can cause a vaginal yeast infection. If you develop itching with white discharge, let your doctor know.
Who needs to be tested along with you
All partners from roughly the last 60 days need to be tested and treated, even if they have no symptoms at all. In men, chlamydia infection very often goes unnoticed.
Fertility after pelvic inflammatory disease: what to check and when
One episode of pelvic inflammatory disease does not mean you will not have a child. It does mean, however, that it is worth being more careful when the time comes to try.
- Don't wait too long: if you have not conceived after six months of trying, ask for an evaluation earlier than the usual twelve. If you are over 35 or have had more than one episode, testing can be done right from the start.
- Tubal evaluation: shows whether the tubes are open or whether there is a hydrosalpinx.
- Early ultrasound: in every new pregnancy, an ultrasound at around the sixth week confirms that the pregnancy is inside the uterus, since the risk of ectopic pregnancy is higher.
- Hydrosalpinx and IVF: fluid from a swollen tube can lower the chances of implantation. That is why, before in vitro fertilization, laparoscopic removal or tying off of the affected tube is often recommended.
You will find general advice on conception and how long to keep trying in our guide on how to get pregnant.
Pelvic inflammatory disease in pregnancy and after menopause
In pregnancy
It is rare, because after the first weeks the gestational sac and the cervical mucus prevent bacteria from moving upward. When it does happen, usually in the first trimester, it is treated in the hospital with intravenous antibiotics that are safe in pregnancy. Abdominal pain with fever during pregnancy always needs immediate assessment.
After menopause
The disease is unusual at this age. When a pelvic abscess is found after menopause, the doctor also looks for other causes, such as diverticulitis or uterine conditions, and the workup is more extensive.
Chronic pelvic pain after the infection: what helps
Some women continue to have pain for months after treatment, without any active infection. The pain is usually due to adhesions or to sensitization of the pelvic nerves.
- First, it is confirmed that the infection has cleared and that the partner has been treated.
- Pelvic floor physical therapy helps when the muscles have tightened because of the pain.
- Medication may include, in addition to common pain relievers, drugs for neuropathic pain.
- Laparoscopy with adhesiolysis (release of adhesions) is considered in selected cases, when the pain is severe and other options have not worked.
Myths about pelvic inflammatory disease
- “It is only a problem for people with many partners.” A single encounter with a partner who has chlamydia or gonorrhea is enough, often without that partner knowing it.
- “The pain is gone, so I am cured.” Symptoms going away does not mean the bacteria have been eliminated. Always complete the treatment.
- “Vaginal douching prevents infections.” The opposite is true. Douching disrupts the flora and makes it easier for bacteria to move upward.
Tubo-ovarian abscess: the most serious form of the disease
When the inflammation is not controlled, the tube and ovary can “stick” together and form a cavity filled with pus. This is a tubo-ovarian abscess.
How it presents
- severe pain on one or both sides of the pelvis,
- high fever that does not come down easily,
- a feeling of pressure in the rectum or difficulty with bowel movements,
- elevated white blood cells and inflammatory markers on blood tests.
How it is treated
Treatment always takes place in the hospital. Smaller abscesses often resolve with intravenous antibiotics alone. Larger ones, or those that do not improve within two to three days, need drainage. This is done either with a needle guided by ultrasound or CT, or laparoscopically. In women who want to become pregnant, the goal is always to preserve as much of the ovaries and tubes as possible.
A ruptured abscess is a surgical emergency. Sudden worsening of pain, pain across the whole abdomen, a rapid heart rate or a drop in blood pressure require going to the hospital immediately.
Questions worth asking your doctor
- Which organism was found, and does my partner need to be tested?
- When should I come back for a follow-up?
- Will I need my tubes checked in the future if I plan to get pregnant?
- Which symptoms mean I should contact you right away?
Frequently Asked Questions
Is pelvic inflammatory disease contagious?
Pelvic inflammatory disease itself is not contagious, but the bacteria that usually cause it, such as chlamydia and gonorrhea, are transmitted. That is why your partner is treated as well.
Can I get pregnant after pelvic inflammatory disease?
Most women who are treated early have no problems. The risk of infertility increases with each new episode and with delays in treatment. If you are having trouble conceiving, a tubal evaluation gives the answer.
How long does treatment last?
Antibiotic treatment usually lasts 14 days. Symptoms improve within two to three days, but the full course must still be completed.
Can you have pelvic inflammatory disease without symptoms?
Yes. The “silent” form is common, especially when caused by chlamydia, and can damage the fallopian tubes without the woman noticing.
Does my IUD need to be removed if I get pelvic inflammatory disease?
Not necessarily. In mild and moderate cases, treatment starts with the IUD left in place. Removal is discussed if there is no improvement within 48 to 72 hours.
When can I have sex again?
Once you have both completed treatment and your symptoms have resolved. Before that, there is a risk of reinfection.
Can it happen again?
Yes. About one in four women has another episode, usually because the partner was not treated or because of new exposure. Condoms significantly reduce the risk.
Do the antibiotics used for treatment affect the birth control pill?
The antibiotics usually used for pelvic inflammatory disease do not reduce the effectiveness of the pill. However, if you have vomiting or severe diarrhea, absorption of the pill may be affected and you will need extra protection.
Can I drink alcohol during treatment?
If your treatment includes metronidazole, no. Alcohol should be avoided during treatment and for 48 hours afterward, because it can cause nausea, vomiting and a rapid heart rate. With other antibiotics, too, it is better to avoid it until you have recovered.
When should I be retested for chlamydia?
If your pelvic inflammatory disease was caused by chlamydia or gonorrhea, retesting is recommended about three months after treatment, because reinfection is common. Testing is also repeated with every change of partner.
Can tampons cause pelvic inflammatory disease?
A tampon on its own does not cause pelvic inflammatory disease. Used correctly, changed every few hours, it is safe. A forgotten tampon, however, can cause a severe vaginal infection and must be removed right away.
