Complications of chlamydial pelvic inflammatory disease
Infertility and ectopic pregnancy
The consequences of missing chlamydial pelvic infection are grave. In a series of classic studies in Sweden, Lars Weström and colleagues established the impact of pelvic inflammatory disease on involuntary infertility in women. The table below summarizes their observations on the subsequent reproductive performance of 2,501 women who, over the period 1960 - 1984, underwent diagnostic laparoscopy [surgical examination of the abdominal cavity through a fibre optic device] because of suspected pelvic infection.
Table 1. Impact of pelvic infection on women's reproductive health. Data from Weström et al., 1992.
The impact of repeated pelvic inflammatory infection on fertility, for a smaller series of patients, is shown in the table below.
Table 2. Percentage of involuntary infertility, by age group and number of infections, in 708 women with laparoscopic evidence of pelvic infection and in 100 controls with normal laparoscopic findings. Data from Weström and Mardh, 1983.
In the case of these Swedish studies, C. trachomatis was by far the commonest identified cause of pelvic inflammatory disease, although their contribution was probably considerably underestimated because of the methods in use at that time. The role of sexually transmitted diseases and of C. trachomatis in particular in ectopic pregnancy was confirmed by a large case control study in France [Coste et al., 1994]. has been The contribution of Chlamydiae to pelvic inflammatory disease varies geographically, by the particular population and by time. Identification rates for C. trachomatis in pelvic inflammatory disease range from 5 - 20% in the United States, to 25 - 40% in Europe [Schachter, 1999], up to 55% in one study in the UK [Bevan et al., 1995] which pursued the causative agents particularly energetically. In Scandinavia the frequencies of both chlamydial and gonococcal salpingitis rose to a peak in the early 1970s reflecting an increase in the underlying sexually transmitted infections, then decreased until the last few years, when a slight increase was seen again. The peak of salpingitis cases in the early 'seventies was mirrored exactly by a peak of ectopic pregnancy fifteen years later in the late 'eighties [Bjartling et al., 2000].
In general, serology has little place in the diagnosis of Chlamydial pelvic inflammatory disease because it cannot distinguish between upper and lower genital tract infection and because antibodies can persist for a long time after infection. This latter property is useful for epidemiological studies. Numerous serology studies have shown retrospectively an association between prior Chlamydial [and, less commonly, gonococcal] infection and involuntary infertility due to obstruction of the fallopian tubes [e.g. Robertson et al., 1987]. It is clear many of these infertile women have no history of prior, symptomatic, pelvic inflammatory disease, they are the victims of "silent" salpingitis. In this respect, hospital-based studies of symptomatic salpingitis do not reflect what is really happening in the population.
| Number of infections || Tubal obstruction || in age group (%) || |
| Age (years): || |
15 - 24
25 - 34
| None (controls) ||0 ||0 ||0 |
| || || || |
| One ||9.4% ||19.2% ||11.4% |
| Two ||20.9% ||31.0% ||23.1% |
| Three or more ||51.6% ||60.0% ||54.3% |
| || || || |
Pelvic pain is considered to be chronic when it has been present for at least 6 months. In the UK, the prevalence of chronic pelvic pain is reported to be 21.5 per 1000 women, comparable to 21.5 for migraine and 41.5 for backache. It has been estimated to account for a fifth of gynaecological referrals. Many conditions cause chronic pelvic pain in women, including pelvic venous congestion, endometriosis, ilio-inguinal nerve entrapment and irritable bowel syndrome [Beard & Dias, 2001]. Pelvic inflammatory disease may be associated with both acute or chronic pelvic pain. In an important study, Buchan et al., 1993 studied hospital readmissions of 1,355 women in the Oxford region of the UK with a clinical diagnosis of pelvic inflammatory disease compared with 10,507 women discharged with other diagnoses. Women with pelvic inflammatory disease were 10 times more likely to suffer from abdominal pain or ectopic pregnancy, 8 times more likely to be admitted for hysterectomy [surgical removal of the womb], and 6 times more likely to suffer endometriosis [Buchan et al., 1993]. Laparoscopic observations indicate that abdominal pain is particularly associated with the presence of moderate to severe pelvic adhesions [Eschenbach et al., 1997] particularly if they involve the ovaries or if they prevent mobility of the uterus, appendages, or bowel [Beard & Dias, 2001]. Pelvic pain through raised isovolumetric venous pressure might also arise as a result of systemic increases in postcapillary resistance secondary to infection-mediated neutrophil activation [see: Foong et al., 2002]. Although no studies of the microbial cause of the pelvic infection were performed by Buchan et al., 1993, other studies suggest that, in the UK, pelvic inflammatory disease and ectopic pregnancy are primarily associated with chlamydial rather than gonococcal infections [Robertson et al., 1987; 1988]. Another study found that women with upper genital tract infection were 7.1 times [95% CI = 2.2-23.0] more likely to report abdominal pain than women with a lower genital tract infection alone [Nelson et al., 1998]. Although clinical examination and careful history taking may help identify the cause of pelvic pain, it is important that a full differential diagnosis and appropriate tests are considered.
Oral contraceptives & PID
A major study of 563 women being treated for pelvic inflammatory disease found that inconsistent condom use was significantly and independently associated with a 2 to 3 times elevated risk for upper genital tract infection. However, neither upper genital tract gonorrhoea nor chlamydia were significantly associated with use of oral contraceptives. Surprisingly no barrier contraceptive method was related to a reduction in upper genital tract disease among women with clinical pelvic inflammatory diseases [Ness et al., 2001].
[MEW] September 2003
NEXT PID pathogenesis
Anonymous (2000). Sexually transmitted diseases quarterly report: genital chlamydial infection, ectopic pregnancy, and syphilis in England and Wales. Communicable Disease Report CDR Weekly 10, 116 - 118. Full article
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