Among teen girls and young adult women, uncomfortable symptoms associated with menstrual periods, normal monthly vaginal changes, or urinary tract infections (UTIs) are common. So patients may think they are no big deal, and they may put off seeing a doctor. For three of my recent patients, they were symptoms of something more serious: pelvic inflammatory disease (PID):
A 21-year-old had lower abdominal pain and menstrual spotting for the last month. Her last menstrual period was more painful than usual.
An 18-year-old had burning with urination and pelvic pain. She thought she had a UTI.
A 14-year-old complained of foul-smelling vaginal discharge and lower abdominal pain.
What is PID? PID is an infection of the female reproductive organs. It usually occurs when sexually transmitted bacteria spread upwards from the vagina to the uterus, fallopian tubes, or ovaries. It can even spread to the covering of the liver.
If untreated, complications include internal scarring, which can lead to infertility or ectopic pregnancies that can cause life-threatening bleeding; an abscess in the ovary or fallopian tube that can likewise damage reproductive organs; and chronic pelvic pain.
PID is very common, yet commonly missed. Although less than half of female adolescents are sexually active, they have the highest rates of PID. An estimated one in five cases of PID occurs in women younger than 19 years, and in one study, adolescents and young women aged 17–21 were twice as likely as other age groups to be diagnosed with PID. Yet the U.S. Centers for Disease Control and Prevention estimates that more than 200,000 cases are missed each year.
Symptoms range from mild to severe. PID is generally diagnosed through a physical examination. In some cases, PID causes only mild symptoms or no symptoms, which can result in delayed diagnosis and inadequate treatment. Patients may present with:
Lower abdomen/pelvic pain or right upper abdominal pain.
Vaginal discharge with foul odor.
Unusually painful menses.
Painful urination or intercourse.
Fever, chills, or vomiting.
What causes PID? Although the bacterial sexually transmitted infections (STIs) that cause chlamydia and/or gonorrhea are commonly involved in PID, they are not the only microorganisms associated with the disease. There are some bacteria that can cause PID that are not routinely tested for, such as mycoplasma. PID is a polymicrobial infection, meaning that even if someone tests positive for one STI, it is still presumed to be caused by multiple organisms. The infection is usually acquired during sex without a condom. It is less common, but bacteria can enter the female reproductive tract when the normal barrier created by the cervix is disturbed, such as after childbirth, miscarriage, or abortion.
Why are teen girls and young women more likely to get PID? One reason is that the cells on a young girl’s cervix are more easily affected by STIs than on an older woman’s cervix. Other risk factors include:
Having multiple sexual partners.
Being in a sexual relationship with a person who has more than one sexual partner.
Having sex without a condom.
Vaginal douching, which upsets the balance of good versus harmful bacteria.
Having had an STI or PID.
PID treatment: not for girls only. Treatment is usually on an outpatient basis with antibiotics that are effective against a broad range of sexually transmitted infections. Male sexual partners from the last 60 days should be evaluated, tested and treated, as well.
Prevention is the best medicine. We may not be able to get our teenagers to delay sex, but we can encourage safer sexual practices including:
Using condoms every time.
Limiting the number of partners.
Asking about a partner’s sexual history.
Getting tested for STIs at least once a year.
Asking sexual partner(s) to be tested, too.
Rima Himelstein, MD, is a pediatrician and adolescent medicine specialist at Crozer-Keystone Health System.