Pelvic Inflammatory Disease (PID): Symptoms, Treatment and Fertility

Pelvic inflammatory disease (PID) is an infection of a woman's upper reproductive organs: the womb, fallopian tubes and ovaries. It happens when bacteria travel up from the vagina and cervix, most often from an untreated sexually transmitted infection, but also after childbirth, a miscarriage or a procedure on the womb. Treated early with antibiotics, PID usually clears completely. When it is missed, delayed or happens more than once, it can scar the tubes and lead to infertility, ectopic pregnancy or long-term pelvic pain. At Yaal Fertility Centre in Chennai, Dr. Rukkayal Fathima and our team see women at every stage, from a first infection to planning a pregnancy years later.

What Is Pelvic Inflammatory Disease?

The cervix (the neck of the womb) normally acts as a gate that keeps bacteria in the vagina from reaching the organs above. In PID, bacteria get past this gate and infect one or more of:

• The womb lining (endometritis).
• The fallopian tubes (salpingitis), the most important part for fertility.
• The ovaries (oophoritis).
• The lining of the pelvis (pelvic peritonitis).

Sometimes a pocket of pus forms around the tube and ovary, called a tubo-ovarian abscess. This is a more serious form that often needs hospital care.

A Medical Condition, Not a Judgement

Many women feel embarrassed to talk about a pelvic infection, and some delay seeing a doctor because of it. PID is a common medical condition. It is not always sexually transmitted, it can happen to women in long, faithful marriages, and having it says nothing about your character. What matters is getting it treated quickly, because time is what protects your tubes.

What Causes PID?

Sexually Transmitted Infections

Chlamydia and gonorrhoea are the best-known causes. Chlamydia in particular often causes no symptoms in either partner, so it can be present for months without anyone knowing. A partner may carry it from a past relationship, years before marriage, without ever having been unwell.

Other Vaginal Bacteria

Many cases are caused by bacteria that normally live in the vagina, especially when the natural balance is upset, as in bacterial vaginosis. Organisms such as Mycoplasma can also be involved. These cases have nothing to do with a new partner.

After Childbirth, Miscarriage or Procedures

Anything that opens the cervix gives bacteria a temporary path upward:

• Childbirth, particularly after a long labour or caesarean section.
• A miscarriage, especially if tissue stays behind.
• An abortion, medical or surgical.
• A D&C, hysteroscopy, endometrial biopsy or HSG test.

Doctors take care to reduce this risk, for example by checking for infection before a procedure. Fever, foul discharge or worsening pain in the days after any of these is a reason to see a doctor promptly.

IUD Insertion, in Rare Cases

A copper or hormonal coil (IUD) does not cause PID on its own. There is a small, short-lived rise in risk in the first few weeks after insertion, mainly if an infection was already present in the cervix. After that, the risk returns to normal. This is why some doctors screen for infection before fitting a coil.

Who Is at Higher Risk?

• Women under 25.
• A new partner, or more than one partner.
• A partner who has had an untreated infection.
• A previous episode of PID.
• Douching, which washes away protective bacteria.

PID Symptoms

PID can feel very different from one woman to the next. Some are clearly unwell; others have mild symptoms or none at all.

Common Signs

• Pain low in the tummy or pelvis, on one or both sides.
• Unusual vaginal discharge, often yellow or green, or with a bad smell.
• Pain during sex, felt deep inside. (Pain or tightness at the entrance is more typical of vaginismus.)
• Bleeding between periods or after sex, or heavier periods than usual.
• Burning or pain when passing urine.
• Fever, chills or feeling generally unwell.
• Lower back ache.

Because these overlap with urine infections, period pain and other conditions, PID is easy to miss. Our guide to irregular periods covers other reasons for changes in bleeding.

Mild and Silent PID

Some women have only a mild ache or slightly more discharge than usual, and many have no symptoms at all. This is called silent PID, and chlamydia is a common cause. The infection can still damage the tubes quietly. Many women first learn they had PID years later, when a fertility test shows blocked tubes.

When to Seek Urgent Care

Go to a hospital the same day if you have:

• Severe tummy pain, especially if it is getting worse.
• High fever with shivering.
• Vomiting and being unable to keep fluids down.
• Fainting or feeling faint.
• Pain with a missed period or a positive pregnancy test, which could be an ectopic pregnancy.

How Is PID Diagnosed?

There is no single test that proves PID. Doctors put together your symptoms, an examination and a few tests.

Examination

A gentle internal examination checks for tenderness when the cervix and the area around the womb are moved. Tenderness here is one of the most important signs.

Swabs and Blood Tests

• Swabs from the vagina and cervix test for chlamydia, gonorrhoea, bacterial vaginosis and other infections.
• Blood tests look for signs of infection and inflammation.
• A pregnancy test, to rule out an ectopic pregnancy, which can feel similar.
• A urine test, to rule out a urine infection.

A negative swab does not rule out PID, because the infection may be higher up where swabs cannot reach. Doctors often start treatment based on symptoms and examination rather than waiting for results.

Ultrasound

A pelvic scan can show swollen, fluid-filled tubes, an abscess, or fluid in the pelvis. In mild PID, the scan is often normal.

Laparoscopy

When the diagnosis is unclear, or treatment is not working, a laparoscopy lets the doctor look directly at the tubes and ovaries through a small cut near the navel. It can also be used to drain an abscess.

PID Treatment

Prompt Antibiotics

PID is treated with antibiotics, usually a combination that covers the range of bacteria involved, taken for around two weeks. Treatment is usually started straight away, before swab results return, because every day of delay can add to damage in the tubes. Your doctor will choose the medicines and schedule.

• Take the full course, even if you feel better in a few days. Stopping early can leave the infection partly treated.
• Expect to feel better within a few days. If you do not, go back to your doctor, as you may need a different treatment.
• A follow-up check confirms that the infection has settled.

When Hospital Care Is Needed

Most women are treated at home. Admission for antibiotics through a drip is advised if:

• You are very unwell, with high fever or vomiting.
• A tubo-ovarian abscess is found.
• You are pregnant.
• Tablets have not helped after a few days.
• The diagnosis is uncertain and an emergency such as appendicitis or ectopic pregnancy needs to be ruled out.

An abscess sometimes needs draining, either by a needle guided by ultrasound or during laparoscopy.

Partner Treatment

If PID may have come from a sexually transmitted infection, your partner needs testing and treatment too, even if he feels completely well. Many men with chlamydia have no symptoms. If only one of you is treated, the infection can pass straight back.

Avoid sex until you have both finished treatment and your doctor says it is safe. This conversation can feel difficult, but it is routine for doctors, and it protects both of you. Your doctor can help explain it.

Can You Keep a Coil During Treatment?

Often, yes. In mild to moderate PID, a coil can usually stay in while antibiotics work. If symptoms do not improve, your doctor may advise removing it.

Complications of PID

The risk of complications rises with delayed treatment and with each repeat infection.

Tubal Damage and Blocked Tubes

The inside of each fallopian tube is lined with tiny hair-like cells that sweep the egg and embryo toward the womb. Infection can destroy these cells and make the inner folds stick together. As the tube heals, scar tissue forms. The tube may become partly or fully blocked, or stay open but no longer move an egg properly. Read more in our guide to blocked fallopian tubes.

Hydrosalpinx

When the far end of a tube seals shut, fluid builds up inside it and the tube swells. This is called a hydrosalpinx. The fluid can leak back into the womb and make it harder for an embryo to implant, even during IVF. See our guide to hydrosalpinx and IVF.

Ectopic Pregnancy

A partly damaged tube can let sperm through to meet the egg but trap the embryo on its way back. The pregnancy then grows in the tube, which is an emergency. Women who have had PID should have an early scan in any future pregnancy to confirm it is in the womb. Our guide to ectopic pregnancy covers its symptoms, treatment and pregnancy afterwards.

Chronic Pelvic Pain

Scar tissue (adhesions) can bind the tubes, ovaries, womb and bowel together, causing pain that lasts months or years after the infection has gone. It may be felt during sex, with periods or at other times.

Scarring Inside the Womb

Less often, severe infection affecting the womb lining, especially after a procedure, can leave scar tissue inside the womb.

PID and Infertility

PID is one of the main preventable causes of infertility in women. Most of this comes from tubal damage. The chance of tubal problems rises with each episode: a single promptly treated infection often leaves no lasting harm, while repeated infections carry a much higher risk.

Why the Tubes Matter

The egg and sperm meet inside the tube, and the embryo spends its first days there before moving to the womb. If both tubes are blocked, natural conception cannot happen. If one tube is blocked or the tubes are damaged but open, pregnancy may take longer and the risk of ectopic pregnancy is higher.

Secondary Infertility After PID

PID can happen after a first baby, for example following delivery or a later procedure, and is one reason women who conceived easily before find it hard the second time. Read our guide to secondary infertility.

Fertility After PID

Many women conceive naturally after PID, especially when it was treated early. A past infection is a reason to get checked sooner, not a reason to lose hope.

When to Get Checked

If you have had PID and have been trying for six months without success, or sooner if you are over 35 or had a severe or repeated infection, ask for your tubes to be checked. You do not need to wait the usual year.

Tests for the Tubes

• HSG: dye is passed through the cervix and an X-ray shows whether it flows freely through the tubes. Read our HSG test guide.
• Sono-HSG (HyCoSy): a similar test using ultrasound and no radiation.
• Laparoscopy: looks directly at the tubes and pelvis and can treat adhesions or a hydrosalpinx at the same time.

Your doctor will also check ovulation, ovarian reserve and your partner's semen, because the tubes are only one part of the picture.

Treatment Options

How IVF Helps

In IVF, eggs are collected directly from the ovaries, fertilised in the laboratory and the embryo is placed straight into the womb. The tubes are bypassed completely, which is why IVF is the main treatment for tubal damage from PID.

Genital Tuberculosis Is Different

Tuberculosis can also damage the tubes and womb lining and is still seen in India. It spreads differently, does not respond to standard PID antibiotics and needs months of TB treatment. If your doctor suspects it, read our guide to genital tuberculosis and infertility.

Preventing PID

Everyday Protection

• Use condoms with a new partner or when infection status is unknown.
• Get tested for sexually transmitted infections before or early in a new relationship, and encourage your partner to do the same. Many couples now include this in a fertility test before marriage.
• Treat vaginal infections fully, and see a doctor if discharge changes.
• Avoid douching, which disturbs the healthy bacteria that protect you.

After Delivery, Miscarriage or a Procedure

• Follow your doctor's advice on avoiding sex and tampons until healing is complete.
• Report fever, foul-smelling discharge or worsening pain promptly.
• Attend follow-up visits.

After an Episode of PID

• Finish every dose of treatment.
• Make sure your partner is treated.
• Get retested if your doctor advises, as repeat infections are common and each one adds risk.

Questions to Ask Your Doctor

• Could my symptoms be PID, or something else?
• What tests do I need, and when will results be back?
• Does my partner need testing or treatment?
• Do I need to come back for a check after treatment?
• Has this affected my tubes, and should I have them tested before trying to conceive?
• What should make me come back sooner?