Clinical Associate Professor Deborah Bateson ( left ) Medical director , Family Planning NSW ; discipline of obstetrics , gynaecology and neonatology , Faculty of Medicine and Health , University of Sydney , NSW .

Dr Jane Goller ( right ) Research fellow , Melbourne School of Population and Global Health , University of Melbourne , Victoria .

Dr Henrietta Williams ( left ) Sexual health physician , Melbourne Sexual Health Centre , Alfred Health , Carlton , Victoria ; and senior lecturer , Melbourne School of Population and Global Health , University of Melbourne , Victoria .

Professor Jane Hocking ( right ) NHMRC professorial fellow , Melbourne School of Population and Global Health , University of Melbourne , Victoria .

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This information was correct at the time of publication : 1 April 2022

BACKGROUND

Pelvic inflammatory disease ( PID ) is a serious reproductive health issue for women . It involves inflammation of the female upper genital tract that is often , but not always , associated with a sexually transmissible infection ( STI ). Untreated PID can lead to tubal factor infertility , ectopic pregnancy or chronic pelvic pain ; therefore , prompt diagnosis and initiation of treatment are paramount to reduce the risk of complications . ^1-3

The diagnosis of PID is based on the clinical history and examination , but with varying severity of symptoms and signs , it can be a challenging diagnosis to make . Younger women are particularly at risk , so always consider a diagnosis of PID in the assessment of women under 30 presenting with recent onset lower abdominal pain . ^{2 , 3}

Also routinely consider the possibility of PID , and ask about symptoms of PID , when providing treatment for women diagnosed with a chlamydial or gonorrhoeal infection .

Given that women at risk of PID are likely to present to general practice and other primary care settings , optimising the diagnosis and management of PID in primary care is crucial .

This How to Treat focuses on the diagnosis and management of acute PID in people with female reproductive organs ( hereafter referred to as women ) in primary care . It aims to ensure GPs can feel confident in

assessing a woman at risk of PID and in making a diagnosis of PID . It also considers other differential diagnoses for recent onset pelvic pain .

WHAT IS PELVIC INFLAMMATORY DISEASE ?

THE term PID encompasses a spectrum

of inflammatory disorders of the female upper genital tract ( endometrium , fallopian tubes , ovaries , pelvic peritoneum ). PID generally occurs as an acute infection of less than 30 days ’ duration that follows the spread of pathogens through the cervix to the endometrium before spreading to the fallopian tubes . PID also encompasses the diagnoses of endometritis and salpingitis . ^{1 , 2}

PID pathogens

In up to 70 % of cases of PID , a pathogen is never identified . ^{4 , 5} Chlamydia trachomatis and Neisseria gonorrhoeae

are well known PID pathogens , and a causal role for Mycoplasma genitalium has been recently established . ^{1 , 6 , 7} It is estimated that about 15 % of new chlamydia infections in women will progress to symptomatic PID . ⁸ Many women with PID will also have bacterial vaginosis ; organisms associated with bacterial vaginosis , such as Gardnerella vaginalis , have been found in the upper genital tract of women with PID . ⁹ However , there are limited data about PID pathogens in Australia . One study in an

Figure 1 . Incidence rate for pelvic inflammatory disease by chlamydia and gonorrhoea test result .

PID incidence rate per 1000 person years

30.0

25.0

20.0

15.0

10.0

5.0

0.0

0.5

3.2

4.2

Australian sexual health clinic identified chlamydia in 19.5 % of women with a diagnosis of PID . ¹⁰ Another Australian study reported that bacterial vaginosis was diagnosed in 21.5 %, chlamydia in 18.8 %, M . genitalium in 4.5 % and gonorrhoea in 2.4 % of women with PID , with 62 % having no pathogen identified . ⁵

Risk factors for PID

PID occurs almost exclusively in sexually

active women , and the main risk factors are related to STI acquisition ( for example , increasing number of sex partners , unprotected sex ). Higher rates of PID occur in younger rather than older women ,

5.7

7.4

8.7

23.1

27.3

Based on Reekie J at al 2017 ¹¹

and young age is one of the strongest risk factors . ⁴

Figure 1 presents data from an Australian cohort study examining the risk of PID associated with chlamydia and gonorrhoea , in which the incidence of PID was higher following gonorrhoea than after chlamydia infection . ¹¹ This study also found that chlamydia conferred a higher risk of PID than no infection , and that women experiencing repeated chlamydia or gonorrhoea infections were at higher risk of PID than women who had one infection . ¹¹ Other evidence also clearly shows that repeat infections with chlamydia or gonorrhoea substantially increase the risk of