Gynecology

Pelvic Inflammatory Disease: Gonococcus, Chlamydia, and the Chandelier Sign

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Pelvic inflammatory disease (PID) refers to infection of the uterus, fallopian tubes, and/or ovaries. The most common infections that cause pelvic inflammatory disease are neisseria gonorrhoeae and chlamydia trachomatis. In fact, both bacteria may be present in the same patient! However, it is not uncommon for other pathogenic bacteria to be present as well. The exact role of most of these other pathogenic bacteria is not well understood.

In order for these organisms to gain access to the uterus, fallopian tubes, and ovaries there must be some breakdown of the normal barriers that separate the vagina from the upper genital tract. Interestingly, a significant number of cases of pelvic inflammatory disease occur just after menstruation when the possibility of pathogenic bacteria gaining access to the upper genital structures is at its greatest. In addition, normal vaginal bacteria can act as a barrier to invading pathogenic strains. Therefore, in some patients with PID the normal vaginal bacterial landscape has been altered in some way, which allows the overgrowth of pathogenic bacteria.

Patients who are at risk for pelvic inflammatory disease are generally those women who are at increased risk of sexually transmitted diseases. Therefore, women with multiple sexual partners, younger age (most cases occur between 15 and 25 years of age), previous history of sexually transmitted disease, and those that do not use barrier contraception (ie: condoms) are all at increased risk.

Signs and Symptoms

Bilateral lower quadrant abdominal pain is a common presenting symptom. Infection and the resulting inflammation that occurs can make having sex painful (ie: "dyspareunia") and can make urinating painful (ie: "dysuria"). In addition, abnormal vaginal odors and discharges are also possible. Like most other serious infections, systemic signs such as fever, nausea, vomiting, and lethargy may also occur.

On pelvic examination patients are extremely tender to palpation of the uterus and ovaries. This is often referred to as the “Chandelier sign” because women will “reach for the chandeliers” because of the discomfort during the exam.

Complications

Complications can be severe if left untreated. Pelvic inflammatory disease can lead to scarring of the fallopian tubes and possible infertility. The risk of ectopic pregnancies is increased in women with a history of PID. Abscesses can form in the ovaries and tubes, as well as in the peritoneal cavity (ie: abdominal cavity). In addition, inflammation of the liver’s capsule can occur in a complication known as Fitz-Hugh-Curtis syndrome. Pelvic inflammatory disease can also lead to infection of the peritoneal cavity (aka: peritonitis).

Diagnosis

Diagnosis of pelvic inflammatory disease is based on clinical signs and symptoms. If lower abdominal discomfort with pain during pelvic examination (ie: cervical motion, uterine, and/or ovarian tenderness) is present, patients should be treated as though they have pelvic inflammatory disease.

There are numerous other criteria that can “support” the diagnosis, but are not necessary to have. They include other signs of infection like abnormal vaginal discharge, fever, elevated white blood cell count, and evidence of gonorrhea or chlamydial infection from laboratory tests.

Definitive diagnosis is made either by biopsy of the upper genital tract, imaging (ie: CT or MRI) that shows edematous fallopian tubes, or disease seen laparoscopically.

Treatment

Treatment of pelvic inflammatory disease is based on the severity of the clinical signs and symptoms, as well as the likely underlying organisms. Patients who are stable can be given oral antibiotics.

Generally a single dose of a third generation cephalosporin like ceftriaxone is given to cover gonorrhea; another antibiotic called doxycycline is given to cover the possibility of co-existent chlamydial infection. Metronidazole may be added to these medications if anaerobic bacteria are suspected.

If the patient appears very sick, is pregnant, unlikely to continue treatment as an outpatient (ie: homeless, destitute, etc), or unable to take oral antibiotics they should be hospitalized and treated with intravenous (IV) antibiotics. Usually a second generation cephalosporin like cefoxitin plus doxycycline (either IV or oral) is given. Clindamycin and gentamicin, as well as ampicillin-sulbactam (Unasyn®) can also be used in certain circumstances. In general, there are numerous antibiotic regimens that can be considered.

Overview

Pelvic inflammatory disease is an infection of the upper genital tract in females. This includes the uterus, fallopian tubes, and/or ovaries. Gonorrhea and chlamydia are the two most commonly isolated bacteria, but many infections are caused by other pathogenic bacteria. Diagnosis is made on clinical signs and symptoms. Treatment is with at least two antibiotics: one to cover gonorrhea and one to cover chlamydia.

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Polycystic Ovarian Syndrome: Hormones Gone Amuck

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Polycystic ovarian syndrome (PCOS) is a well recognized disorder of androgen excess in females. The pathology behind this disorder is a cyclic process related to obesity and hormone excess.

The cycle begins when luteinizing hormone from the pituitary gland stimulates the ovaries to produce an androgen known as androstenedione. Androstenedione travels in the blood stream to adipocytes (ie: fat cells) where it gets converted to a specific estrogen called estrone. Estrone then travels in the blood stream to the pituitary gland where it stimulates the release of more luteinizing hormone.

The excess luteinizing hormone stimulates the ovaries to produce more androstenedione. At this point, some of the excess androstenedione gets converted to testosterone, which causes the signs and symptoms of polycystic ovarian syndrome; the rest of the androstenedione gets converted to estrone in fat cells which further fuels the cycle.

PCOS Pathology

Signs and Symptoms

The signs of polycystic ovarian syndrome are related to excessive estrogens and androgens. Excess androgens can cause hirsuitism (ie: growth of facial hair), acne, and oligo- or amenorrhea (ie: decreased frequency or lack of menstrual cycles, respectively). If severe enough, some women may have deepening of the voice and male-like balding patterns.

In addition, the elevated estrogen levels (ie: estrone) stimulate the proliferation of endometrial tissue resulting in abnormal uterine bleeding. If this occurs for a long enough period of time the patient is at risk for endometrial carcinoma.

Patients with polycystic ovarian syndrome are also at risk for other metabolic and cardiovascular diseases. Some patients develop diabetes mellitus, hypercholesterolemia, and hypertension. A substantial portion of patients also have co-existent metabolic syndrome.

Diagnosis

Diagnosis is made when at least two of the following three criteria are met:

(1) Oligo- or anovulation (ie: decreased frequency or lack of ovulation)
(2) Blood tests consistent with elevated androgen levels
(3) Polycystic ovaries seen on pelvic ultrasound

The name polycystic ovarian syndrome is somewhat of a misnomer because you do not need to have polycystic ovaries to be diagnosed with PCOS!

In addition laboratory data that supports the diagnosis of polycystic ovarian syndrome is an increased luteinizing hormone to follicle stimulating hormone ratio (increased LH:FSH), estrone levels greater than estradiol levels, as well as elevated androstenedione and/or testosterone levels.

Treatment

Treatment of polycystic ovarian syndrome is with birth control pills (oral contraception). The birth control pill decreases the release of luteinizing hormone by the pituitary, and breaks the cyclic pathology illustrated above.

In women who wish to become pregnant a medication known as clomiphene may be used. It is an anti-estrogen that ultimately causes an increased release of follicle stimulating hormone by the pituitary. The resulting increase in follicular development in the ovaries increases the odds of successful ovulation. Interestingly, an anti-diabetes medication known as metformin also increases the rates of ovulation and pregnancy in PCOS patients.

Since many patients also have metabolic syndrome it is important to begin treatments as necessary to control co-morbid conditions. Obese women should be encouraged to lose weight. Patient’s with diabetes and insulin insensitivity should be started on metformin. Patients with hypercholesterolemia may benefit from statin therapy.

Overview

Polycystic ovarian syndrome has a cyclic pathology related to obesity and elevated hormones. It causes masculinization with symptoms and signs like increased facial hair growth, balding, and lack of ovulation. Patients are also at risk for developing diabetes and other stigmata of the metabolic syndrome. Diagnosis is based on a combination of elevated androgens, polycystic ovaries, and abnormal menstrual cycles. Treatment is usually with oral contraception, although in women who wish to conceive, medications like clomiphene may be used.

References and Resources