Pelvic Inflammatory Disease (PID)

What is pelvic inflammatory disease?

Pelvic inflammatory disease (PID) is a bacterial infection that begins in the vagina and cervix and moves to the upper genital tract (such as the fallopian tubes, uterus, and/or ovaries). It’s a serious complication of sexually transmitted infections (STIs). Chlamydia and gonorrhea are the two most common causes. Each year, PID is diagnosed in more than 1 million women, many of whom are teens and adolescents.

In the U.S., 4.4% of women (2.5 million) 18 to 44 years of age have a history of PID.

PID, if not prevented or treated, can be harmful and cause permanent problems, such as:

• Infertility

• Chronic pelvic pain

• Abdominal infections

• Ectopic pregnancy

People who know about PID and know how to protect themselves can decrease their risk of getting it. This guide is for anyone who wants to know more about the diagnosis, treatment, and prevention of PID.

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What causes PID?

PID is caused by germs related to STIs in about 85% of cases. Bacteria move from your vagina and cervix upward into the uterus, ovaries, or fallopian tubes, causing a full-blown infection. Inflammation from the infection causes scarring and other damage to the reproductive organs.

Neisseria gonorrhoeae and Chlamydia trachomatis are the most common bacterial causes of PID. Approximately 10% to 15% of untreated chlamydial or gonorrheal infections found in the cervix will eventually progress to PID. Typically, PID due to gonorrhea is more severe than PID with other causes. PID caused by chlamydia is less likely to cause symptoms, which is called subclinical PID. This is concerning because even with mild or no symptoms, the disease can still cause short-term and long-term health problems.

Ten percent of untreated chlamydial infections progress to PID.

In most cases, though, PID is assumed to be caused by an assortment of microbes. Even if gonorrhea or chlamydia are present, chances are that these will not be the only microbes causing the PID.

Other microbes that are normally found in the cervix and vagina have been associated with PID, including many of the bacteria responsible for bacterial vaginosis (BV).

Experts are unsure about whether BV causes PID, though, and whether screening for and treating for BV decreases the rate of PID.

How common is PID?

PID is most common among women between 18 and 44 years old, but it can affect any woman who is having unprotected sex. Based on a national survey, 4.4% of women (2.5 million) between ages 18 and 44 in the U.S. reported having PID.

Who is most at risk for PID?

Several things can put you at greater risk for PID. These include having:

• History of a STI, such as gonorrhea and/or chlamydia

• More than one sexual partner

• A sexual partner who has other sexual partners

• History of PID

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Douching can also increase your risk. This is because douching may push bacteria up to the uterus and fallopian tubes from the vagina.

What are the symptoms of PID?

Symptoms of PID can range from mild to severe. Some women have no symptoms at all. Even without symptoms, PID can still cause severe damage to your reproductive organs. If you have any of the following symptoms of PID, it’s important to see your healthcare provider right away:

• Abnormal vaginal discharge, including a change in smell and color from what is normal for you

• Mild ache or pain in the lower abdomen, pelvis, or right upper abdomen

• Fever (100.4°F or higher) and chills

• Painful urination

• Painful sex

• Nausea and vomiting

You may not realize you have PID if your symptoms are mild, but your healthcare provider might suspect PID if they can’t find another cause. Unfortunately, there is no specific test to diagnose PID. Confirmation of PID is based on your pelvic examination, symptoms, and history of previous PID or STIs.

Additionally, your provider may want to rule out any other possible causes of your symptoms, such as:

• Appendicitis

• Ectopic pregnancy or rupture

• Endometriosis

• Endometritis

• Ovarian cyst rupture

• Urinary tract infection

What happens if PID isn’t treated?

If PID isn’t treated, it can cause serious health problems. Infection and inflammation in the reproductive organs can lead to:

• Abscesses (pockets of infection) in the reproductive organs or pelvis

• Adhesions (scar tissue that sticks to organs in the abdomen and pelvis)

• Chronic pelvic pain

• Infertility and ectopic pregnancy due to scarring blocking the fallopian tubes

In fact, one study showed that women between 20 and 24 years of age with PID developed chronic pain in 18% of cases, ectopic pregnancies in 8.5% of cases, and infertility in 16.8% of cases.

A rare complication of PID is called Fitz-Hugh–Curtis syndrome (FHCS). It occurs when the infection leads to scarring and adhesions in the tissues around the liver. It causes right upper abdominal pain, fever, and vomiting. FHCS is treated with antibiotics, but it may require hospitalization.

After having PID, 1 in 8 women report difficulties getting pregnant.

Can you still have PID even if you don’t have symptoms?

Yes. Because PID and STIs that cause PID may not always have symptoms, you may need to talk to your healthcare provider about testing. If you have any of the risk factors mentioned above, it’s important that you get tested.

Getting a diagnosis

There’s no one simple test to confirm that you have PID. Your healthcare provider will make the diagnosis based on the signs and symptoms you’re having, your health history, and a physical examination. Here’s what to expect from your office visit.

Your provider will do a pelvic examination to check for abnormal discharge from your vagina or cervix and tenderness or pain in your genital organs.

Your provider may order the following tests to figure out if you have PID, or if it’s something else:

• Vaginal swabs to test for infection, such as chlamydia and gonorrhea

• A urine sample to test for a urinary tract infection

• A urine or blood pregnancy test

• Scans of the pelvis, such as ultrasound, CT, or MRI, to look at your internal organs and check for an abscess

• Diagnostic laparoscopy, in which a small camera is used to look inside your pelvic cavity

• Endometrial biopsy, in which your provider collects a sample of tissue from the lining of the uterus so it can be examined under a microscope

If your provider thinks you could have PID, they may recommend treatment even if you are still waiting for certain tests and results. Any delay in starting treatment can lead to health and fertility problems in the future.

How is PID treated?

The best treatment for PID is to take two — but usually three — antibiotics at the same time. The full course of treatment is 2 weeks, but it can be longer if you don’t get better or you need to be treated in the hospital. The antibiotics are usually taken as pills, although one usually needs to be given as a one-off dose as an injection into a muscle (intramuscular). If you need treatment in the hospital (because you are pregnant, have a high fever, or another medical complication), then you will get some of the antibiotics through a tube inserted in a vein (intravenous).

Here is a typical antibiotic combination for PID if you’re being treated out of the hospital:

• Doxycycline pills (100 mg) taken twice a day for 2 weeks

• Metronidazole pills (500 mg) taken twice a day for 2 weeks

• A one-off shot of a cephalosporin antibiotic like ceftriaxone intramuscularly

Can I get PID more than once?

Yes, you can, so it’s important to be careful. Once you’ve had PID, you’re at higher risk of getting it again. You can get PID again if you get a STI, if your partner wasn’t treated for a STI and they pass it back to you, or if your treatment for PID didn’t work completely. If you or your partner get a STI, avoid having sex until you both have finished your treatment so that you don’t reinfect each other.

Can PID be treated without a visit to your healthcare provider?

No. In order to get a correct diagnosis and start the right treatment, you’ll need to see your provider in person. They need to assess your signs and symptoms and do a pelvic exam, which can’t be done virtually or over the phone. While it might sound inconvenient, or make you nervous, remember that getting treated as soon as possible is the best way to avoid long-term health problems for PID.

How to prevent PID

Fortunately, there are steps you can take to help prevent PID. Not every single case can be prevented, because PID is not always caused by a STI. However, by practicing safe sex and not douching, you can lower your risk of developing PID. Douching can remove the healthy bacteria that live in the vagina, and it can cause unhealthy bacteria to travel up the reproductive tract. This is why it’s important to avoid it.

If you are having sex, you can take the following steps to decrease your risk of getting STIs and PID:

• Use condoms every time you have sex.

• Get tested and ask your partner to get tested: Communicate your STI results with each other.

• Be monogamous: This means having sex with one partner and no one else.

• Limit your number of sex partners: Your risk of getting STIs goes up with the number of partners you have.

Since STIs play a major role in developing PID, the CDC recommends screening for women who are at risk of getting them. Chlamydia and gonorrhea screening each year is recommended for all sexually active women younger than 25 years old as well as older women with risk factors such as new or multiple sex partners, or a sex partner who has a STI. In addition, treatment of infected women and their sexual partners right away can also help minimize risk of PID.

Getting a prescription

All treatments for STIs and PID require a prescription. For many women, visiting a provider and talking about their symptoms can be embarrassing or uncomfortable. It may help to know that providers are used to seeing symptoms like yours on a regular basis. You can see a provider in different settings, such as a family medicine or gynecology clinic, as well as health centers like Planned Parenthood and your local health department. If you really don’t want to do a face-to-face visit, there are several services that can provide a diagnosis and prescription online.

If you think you could have a STI, consider scheduling a consultation with an online doctor through a telehealth service. One example is GoodRx Care.

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Costs and savings tips

You may get STI testing for free or at a reduced price if you have health insurance. STI testing can also be free or low cost with Medicaid plans and other government programs, such as those offered by your local health department. And some clinics, including many Planned Parenthood and other health centers, give free or low-cost STD tests, depending on your income.

Discussion guide

If you’re feeling anxious about your visit, it might help to be ready with some questions. Here are some questions and discussion points you can use when you meet with your HCP.

• Do I have PID? If so, what caused it?

• Do I have an STI? Can I be screened for STIs?

• Should my partner be tested and treated?

• What medication do I need? What are the side effects?

• What are my health risks after getting PID? Will this affect my fertility?

• Can I get PID again? How do I prevent it?

• When can I resume sex after treatment?

• What should I be on the lookout for?

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Written by:

Camille Moreno, DO, NCMP

Camille Moreno, DO, NCMP, is a women’s health specialist currently practicing at Duke University Medical Center in obstetrics and gynecology. She earned her bachelor of science degree in biology from Virginia Tech and her Doctor of Osteopathic Medicine from Virginia College of Osteopathic Medicine.

Edited by:

Sophie Vergnaud, MD

Sophie Vergnaud, MD, is the Senior Medical Director for GoodRx Health. An experienced and dedicated pulmonologist and hospitalist, she spent a decade practicing and teaching clinical medicine at academic hospitals throughout London before transitioning to a career in health education and health technology.

Reviewed by:

Mandy Armitage, MD

Mandy Armitage, MD, has combined her interests in clinical medicine with her passion for education and content development for many years. She served as medical director for the health technology companies HealthLoop (now Get Well) and Doximity.

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