Women Talk: Sex, multiple partners, and the risk of pelvic inflammatory disease

Melissa, a 32-year-old bank employee, came to see me because of persistent fever and pain in the lower abdomen for about three days. She had self-medicated with paracetamol, and the symptoms somehow abated. But she had to rush over to the clinic when the pain became more intense a few hours earlier.

On examination, she had a high fever (38.7⁰C) and she cried out in pain when deep pressure was applied on her lower abdomen. She had moved her bowels that morning, and there was no vomiting. On internal examination, there was a green, foul-smelling discharge in the vagina, and pain when I touched her cervix. I explained to her that the physical examination seemed to indicate pelvic inflammatory disease. By then she had admitted to having unprotected sex with her 30-year-old boyfriend who, according to her, had several other sexual partners.

Sexual contact

Pelvic inflammatory disease (PID) affects a woman's upper pelvic organs, especially the fallopian tubes, and may include the uterus, the ovaries, and the surrounding areas in the abdomen. The two most common causes (although not limited to them) are Neisseria gonorrhea, and/or Chlamydia trachomatis. These bacteria are transmitted through sexual contact – vaginal, oral, or anal.

There are some myths surrounding PID, a sexually-transmitted disease. Inanimate objects like towels, door handles, or even toilet seats in public lavatories are often blamed as sources, but these cannot harbor the pathogens long enough for them to infect a person and to cause PID. While there is a need to be careful while using unfamiliar toilets, especially when traveling, it is only sexual activity that can transfer PID-causing microorganisms between partners.

Many times, the first symptoms of the infection will be mucus-filled and smelly discharges from the cervix (cervicitis) or the vaginal lining (vaginitis). Often there's also painful urination because of infection of the urethra, the opening where urine comes out (urethritis), and/or infection of the bladder (cystitis). The bacteria could ascend and infect the pelvic organs, hence the lower abdominal pain along with fever.

Infertility & ectopic pregnancy

Microorganisms that cause PID have a predilection to infect the inner lining of the fallopian tubes (salpingitis), so that one dreaded sequel is infertility, or inability to have a child. In the aftermath of the infection, the small passageways through the tubes become blocked with scar tissue, making it impossible for the sperm to pass through to meet the egg. There are laborious microsurgical procedures, however, that trained specialists can do to open the blocked tubes.

At times, the small sperm passes through the scarred tube and succeeds in fertilizing the egg; but the larger fertilized ovum, en route to the lining of the uterine cavity for implantation, cannot pass through the same opening. The fertilized egg is then retained in the tube, implants there, and ectopic pregnancy – when the baby forms outside the womb – ensues. When ectopic pregnancy is suspected, a history of previous PID is a red flag for gynecologists.

Another worrisome complication of PID is chronic pelvic pain. Even after oral and/or intravenous antibiotics, some infection can remain and become symptomatic again when one's immunity becomes weakened. Through the years, a previously infected woman may suffer from on and off pain in the pelvis, especially during sexual intercourse.

For women troubled with recurrent pain, some gynecologists offer a “pelvic clean-up” which means removal of the uterus and the fallopian tubes and ovaries. This option, of course, is for those who no longer want to have children.

Casual sex can kill

When PID is diagnosed either clinically or in positive swabs in the laboratory, the doctor usually prescribes antibiotics for a certain number of days. After two or three days, the pain may disappear, and it is very tempting not to finish the whole course. Remember though, that the inflammation might have subsided but the infection is still there. A full course of the antibiotic is strongly recommended.

At times, intravenous medicines are needed, especially when the patient comes in with severe pain and high-grade fever. The IV therapy is meant to prevent sepsis, meaning the infection has been carried by the blood stream throughout the body. In some cases, when the body’s thermal regulators no longer work, there is no fever or the patient has below normal temperature, and may experience chills. By this time the patient is very sick or near death, and needs to be monitored in the ICU.

So yes, casual sex could, indeed, kill. This is why a pelvic clean-up is also considered when a “tubo-ovarian complex” is present: that means the infected tubes, and parts of the ovaries, have been transformed into a mass containing abscess and infected debris in the pelvis. This is the body’s attempt to contain the infection.

Multiple sex partners

Together with the worry about multiple organ infections from PID, the spectre of HIV (human immunodeficiency virus) infection is always present. We advise tests for HIV when confronted with patients who have PID, especially those with multiple partners, or if their partners have had sex with others. This is also recommended for those with history of sexual contact with high-risk individuals, like commercial sex workers.

The partner, of course, shouldn’t be forgotten. In the case of my patient Melissa who insisted that she was faithful to her boyfriend, I had to ask her partner to be tested as well. This will prevent reinfection on her part, and also ensure the male partner’s health. Many Filipino males do not wish to be seen and examined by an OB-GYN, but they could be referred to a urologist who can examine them for sexually transmitted diseases.

Women need to be cognizant of the serious complications of pelvic inflammatory disease. Early consultation with the doctor could mean saving the fallopian tubes from destruction. Childbearing potentials are maintained, and chronic pelvic pain avoided. Thus, monogamy for both partners is advised. – YA, GMA News
 

Dr. Alice M. Sun-Cua is an author and practicing obstetrician-gynecologist at the San Juan de Dios Hospital in Pasay City.