1. Prevention of Complications of PID Roberta B. Ness, M.D., M.P.H. University of Pittsburgh Graduate School of Public Health

2. What is Pelvic Inflammatory Disease (PID)? Infection involving the uterus, fallopian tubes, ovaries or other upper genital tract sites Most often caused by Chlamydia and Gonorrhea Other STDs and lower genital tract infection may cause PID

4. Why worry about PID Morbid Common By the time symptoms manifest it may be too late!

5. “… Then in 1975, I had a bout of painful cramps which, as it turned out, were caused by a severe infection. My horrified gynecologist took out the IUD and prescribed large doses of antibiotics. He also warned me that I might have trouble having children.” From: “A cash settlement but no apology” NY Times 2/99

6. “He was right, though I didn’t find out for more than a decade. I had to fall in love, get married and spend a few years trying to conceive before an X-ray showed that my fallopian tubes were scarred and completely blocked. My husband and I tried in-vitro fertilization three times but were unsuccessful in having children.” From: “A cash settlement but no apology” NY Times 2/99

8. PID and Infertility One fifth of women who have at least one episode of PID may become infertile Half of women with three or more episodes of PID may become infertile

9. Infertility Prevalence 4.9 million women aged 15-44 2.2 million women without children

10. Causes of Infertility and Rates of Pregnancy during Follow-up in the United States CausePrevalence (%)Pregnancy Rate (%) Ovulatory failure1644 Tubal damage1226 Semen factor1838 Endometriosis2531 Unexplained1755 Multiple28- All-38 From Jones HW, Toner JP. The infertile couple. N Engl J Med 1993:1710-1715.

11. PID and Chronic Pelvic Pain One fourth of women with acute PID may experience subsequent chronic pelvic pain

12. PID and Ectopic Pregnancy One in ten women may have an ectopic pregnancy in their first pregnancy following PID Tubal pregnancy is the leading cause of first-trimester, pregnancy- related deaths in American women

13. Prevalence of PID 8% of all American women of reproductive age are reported to have received treatment for PID in 1995 Over one million American women seek treatment for PID annually

14. The Incidence of STDs 333 million new cases of curable STDs globally U.S. rates are 50 – 100 times higher than other industrialized nations 85% of the most common infectious diseases in the U.S. are sexually transmitted

15. Incidence of STDs in the U.S. 12 million new cases of STDs in the U.S. yearly 3 million of these cases are among teenagers

16. Gonorrhea – Reported rtes: United States, 1970 – 1997 and the Healthy People year 2000 Objective Gonorrhea 2000 objective 100 300 500 Rate (per 100,000 population) 197019971976198219881994 CDC

17. Symptoms of Chlamydia Many infected individuals experience no symptoms 75% of women experience no symptoms Men: watery or milky discharge from the urethra, painful urination Women: Painful urinary, increased vaginal discharge, possible light bleeding between periods

18. Bacterial STDs and Pelvic Inflammatory Disease Tertiary Prevention PEACII Secondary Prevention DAISY Primary Prevention GIFT

19. Prevention Stop AIDS

20. When the opportunity for prevention is missed ……

21. Diagnosis and Treatment of PID  Pelvic examination  Test for STDs  Outpatient antibiotic therapy  Inpatient therapy  200,000 to 300,000 women hospitalized will undergo surgery

22. Guidelines for hospitalization The guidelines for making the determination about whether a women should be hospitalized or not, which have been published by the CDC, are a little open to interpretation. If the diagnosis is uncertain, which it almost always is, then you can consider hospitalizing the women for PID. If a patients is an adolescent, gets severe illness, this precludes outpatients management. A clinician would have a lot of flexibility in interpreting these guidelines.

23. What Factors Influence the Decision to Hospitalize patients with PID? R. Ness, K. Delaney, R. Rolfs, J. Gale

24. Hospitalization from Two Hospital-based Settings versus Non-Hospital Setting Emergency Department 21% Hospital-Based Clinics 26% Out-of Hospital Clinics 3.5%

25. Results suggest that hospitalization for PID is considered to be largely discretionary Reflects uncertainty about the relative effectiveness of outpatient versus inpatient treatment