Bacterial vaginosis - the mildest pelvic inflammatory disease

And it's not sexually transmitted pelvic inflammatory disease.

Half the time it's asymptomatic, not even noticed. It is probably the commonest cause of an unpleasant smelling discharge, due to ordinary anaerobic germs, rather than Chlamydia, gonorrhoea etc which are sexually transmitted.

It's basically a disturbance of the healthy germ population of the vagina, probably due to poor health and lowish hormone levels.

Intravaginal lactobacillus is reasonably effective1 for eradicating symptoms, as are antibiotics2 (clindamycin, metronidazole, tinidazole.) The NNT is generally 3.





Most pelvic inflammatory disease in young women is an STD

This can range from symptomless to very severe (tubo-ovarian abcess) needing hospitalization.

Virtually asymptomatic Chlamydia infections can still lead to blocked Fallopian tubes and infertility.

Symptoms may be fairly vague, such as deep pain with intercourse, a little abnormal bleeding or abdominal pains.

Tenderness in the lower abdomen can be fairly mild.

If you've had unprotected intercourse and there is any suggestion of something wrong inside, it's very important to have a checkup for your own sake and any future partners.

The doctor will probably need to do an internal examination, to see if there is tenderness in the middle over the uterus, at the sides over tubes or on moving the cervix to stretch tissues at the sides. If you are tender and at risk of infection, they may start you on treatment while waiting for the results of swabs, to help avoid the condition becoming chronic.

You will be asked to tell your partners to have checks too. This is to help avoid them passing it on to others as well





Multiple symptoms in chronic pelvic inflammatory disease

Irritable bowel syndrome, dyspepsia and other labels abound in chronic pelvic inflammatory disease.

One 27 year old woman had previously come in feeling run down, depressed, unable to cope with her children and to relax and unwind.
Further symptoms now were feeling hot and flushed, hot in bed at night, for 1 year. She was very tired, had muscle aches, loose bowel actions and itchy back.

On examination she was significantly tender right across her lower abdomen.

A blood test for inflammation showed an ESR of 40 - definitely elevated.

Her PID was treated with tetracycline injections (this was 1981.)

She hadn't specifically complained of her tummy pain when she first came in, but two weeks later I noted "no abdominal pains at present, more energy, less heartburn."
At one month her notes read.."thinks she is better - can relax more, things aren't worrying as much, abdominal pains are nearly all gone, not sweaty now, pains and pins and needles in legs all better, nails are improving."




And multiple organisms and pathology

Mrs. W had vaginal thrush on and off for years, was very tired and very nauseous.
On examination she had separate areas of tenderness at the top and bottom of her abdomen.
Initial treatment was nystatin, acidophilus and digestive enzymes. This settled her itchy bottom and improved her nausea.

Her post hysterectomy PID was then treated with antibiotics, and her abdominal pain improved along with flushes.

Her thrush wasn't just vaginal.

Later she benefited from going off dairy products, adding thyroid replacement therapy and some vitamin E for her sore breasts.





Abdominal tenderness in pelvic inflammatory disease

People often have very extensive abdominal tenderness. Mrs X, aged 35 had this...

abdo tenderness pattern in PID

The notes read.."Abdo pain, flat. gets tight across throat, asthma, indigestion and constipation, fever, yellow vaginal discharge, aches and pins and needles."

She had previously had two laparoscopies without any firm diagnosis being reached.

On antibiotic treatment, the next day she had "picked up a lot" and mentioned that she had a miscarriage 9 years earlier, which had "poisoned her system."

By the fourth day, she had "lot more life in her, nearly 100% to what she was." By the fifth day, she was "feeling the best she has for ages - sleeping well, pain not as severe. Night sweats have got less. Still has the discharge."



Another woman, aged 35, illustrates the value of repeated recording of the pattern of tenderness.

She had a long history of abdominal pain, worse before periods and worse after passing urine. She was very sore on sexual intercourse. She had continual low back pain.

On pelvic examination it hurt on pressure on her uterus or moving her cervix from side to side. Speculum examination showed yellow discharge from the inside of her uterus.

This is a chronic relapsing condition. The page below was from one flare up...

PID  abdominal tenderness

The following page showed examination a month later...

PID resulution




Intrauterine contraceptive devices and PID

Follow up of 57728 women, all those who had levonorgestrel or copper-T IUD insertions at Kaiser Permanente Northern California clinics from Jan'05 to Aug'09, found PID had developed in about 1/200.3

Notes and references

1. Oduyebo et al. The effects of antimicrobial therapy on bacterial vaginosis in non-pregnant women. Cochrane Reviews 2009, Issue 3. Article No. CD006055. DOI: 10.1002/14651858.CD006055.pub2.

2. metronidazole 500 mg twice daily, tinidazole 500 mg twice daily, or tinidazole 1 g twice, all for 7 days, were equally effective and tolerated, in a trial reported in 2010 by Schwebkeet al.
http://www.ajog.org/article/S0002-9378%2810%2902157-5/abstract

3. http://journals.lww.com/greenjournal/Abstract/2012/12000/Neisseria_gonorrhea_and_Chlamydia_trachomatis.10.aspx





Another person's PID story


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