Our Bodies, Ourselves (133 page)

Most cases of PID are caused by microorganisms responsible for sexually transmitted infections. They can get into the body during sexual contact with an infected man or woman.
18
If you are carrying these microorganisms, certain procedures or reproductive events can push them farther into your body, including miscarriage, childbirth, abortion, or other procedures involving the uterus, such as endometrial biopsy, hysterosalpingogram (X-ray of the reproductive tract), IUD insertion, or donor insemination. If you have chronic PID and antibiotic treatment doesn't help, your sexual partner(s) may be reinfecting you. Men can be carrying the organisms that can cause PID without having symptoms, so they must be tested and treated, too, and they should use a condom during intercourse.

The risk for developing PID is higher if you are exposed to infected secretions—especially infected semen—during menstruation and ovulation, when your cervix is more open and your mucus is more penetrable. Women using some IUDs are also at higher risk during the first four months after insertion. In some parts of the United States, gonorrhea still causes most PID. In other areas, chlamydia is more often the cause of PID. Current guidelines recommend annual chlamydia screening for women age twenty-five and under who are having sex, to find and treat this infection before it causes PID.

The complications of PID can be very serious. If untreated, PID can turn into peritonitis—a life-threatening condition—or into a tuboovarian abscess. It can affect the bowels and the liver (causing perihepatitis syndrome). Months or years after an acute infection, infertility or ectopic pregnancy can result if your fallopian tubes were damaged or clogged by scar tissue. PID can also cause chronic pain from adhesions or lingering infection. In the most extreme cases, untreated PID can result in death.

Because so much PID is caused by sexually transmitted organisms, preventing PID involves preventing sexually transmitted infections. You can reduce your risk by using condoms and engaging in safer sex practices. For more information, see
Chapter 11
, “Sexually Transmitted Infections.”

If you could know right away exactly which organisms were causing your PID, you could get the right antibiotics. But pinpointing the organisms often takes some tests that may be expensive and not readily available. Sometimes organisms infecting the uterus and fallopian tubes don't show up in a cervical culture. You may be told that your chronic cystitis is caused by trauma to the urethra during intercourse when it's really a sign of PID, or that you got infected by wiping yourself from back to front, when you really have a sexually transmitted infection. You may be told that you have a spastic colon or an emotional, not a physical, problem, when that is not true. Try to have your situation thoroughly assessed, particularly if symptoms persist despite treatment, or seek a second opinion.

Blood tests can help indicate whether you have an infection but won't always tell you which one. Sometimes an endometrial biopsy can find hard-to-culture organisms, but if it is not done carefully, this procedure can spread germs from the cervix and vagina to the uterus. In some cases, ultrasound, including vaginal ultrasound, may be useful. A definitive diagnosis often requires laparoscopic surgery.

Most experts seem to agree that since your health and fertility are at stake, you should start treatment while waiting for test results. Both you and your partner must be treated. If your partner continues to carry the microorganism(s), you will be reinfected. Taking the wrong drugs can make organisms more difficult to get rid of; however, the practical strategy is to begin treatment, then adjust it according to what cause is found. Once you start taking antibiotics, you cannot get an accurate culture again until at least a couple of weeks after you stop taking them.

Therapy lasts at least ten to fourteen days. You should receive two different kinds of antibiotics, since more than one organism may be involved. Remember to take all your antibiotics, even if your symptoms are gone, so that antibiotic-resistant strains of microbes will be less likely to develop. (See the Centers for Disease Control and Prevention website for more information about antibiotic resistance: cdc.gov/drugresistance.) Antibiotics can cause yeast overgrowth in the vagina, so you may need something to keep the yeast in check while trying to cure the much more serious PID (see
“Yeast Infections”
).

Many experts recommend that all women with PID be hospitalized for treatment, but not all physicians follow these recommendations. Most women are hospitalized in the event of an acute attack, to get intravenous (IV) antibiotics. If you're still not cured, it may be because you got the wrong antibiotic, have a pelvic abscess, or were reinfected by a partner.

You may be urged to have a hysterectomy if the doctor thinks that PID has damaged your pelvic organs beyond repair. Also, emergency hysterectomies are done in some cases of acute PID (for example, when an abscess ruptures). If the infection is in your urinary tract, as it often is, then hysterectomy does not eliminate it. Hysterectomy is rarely necessary for PID, except in cases of persistent, debilitating PID.

Avoid intercourse until you have felt completely well through an entire monthly cycle and your partner(s) have had negative test results for all STIs. You can have a recurrence of PID months after the initial infection is cleared up, particularly if you don't keep up daily health routines or are under too much stress.

There are some things you can do to help alleviate discomfort while you wait for test results to come back and for antibiotics to start working. Very hot baths and a heating pad applied directly to the lower abdomen help relieve pain and bring disease-fighting blood to your pelvis. You can soak a cotton cloth in castor oil, place it on the abdomen, cover it with plastic wrap, and then put a heating pad or hot water bottle on top to bring a maximum amount of heat to the pelvic area. Ginger root compresses and taro root poultices may relieve pain, keep the area loose and freer from adhesions, and dissolve already formed adhesions. Do not douche or use tampons; doing so may force microorganisms up into your uterus. Do not reuse a douche bag that may be harboring infectious organisms.

Certain herbs and teas may be useful against infection of the reproductive and urinary tracts. Raspberry leaf tea can strengthen the reproductive system; cranberry juice may help with UTIs. Try to eat wholesome, fresh foods and reduce stress as best as you can.

Endometriosis is a puzzling hormonal and immune system disease in which tissue like that which lines the inside of the uterus (endometrium) grows outside the uterus. It affects girls and women from before a first menstrual period to postmenopause and can cause pain, infertility, and other problems. There are an estimated more than 6 million girls and women in the United States alone who have endometriosis.

The most common symptoms of endometriosis are pain before and during menstrual periods, pain during or after sexual activity, infertility, fatigue, and heavy bleeding. Other symptoms such as lower-back pain with periods and intestinal upset with periods (including diarrhea, painful bowel movements, and/or constipation) are also common.

Many with endometriosis also experience a range of immune disorders, including allergies, asthma, eczema, and certain autoimmune diseases. Other symptoms may include irregular bleeding, pain related to urination, yeast infections (gastrointestinal or vaginal), and abdominal bloating. Infertility affects 30 to 40 percent of women with endometriosis, and about a third of women with infertility have endometriosis. (If you know you want to conceive, be aware that delay in diagnosis and treatment may make pregnancy less likely if the disease advances.)

Women and girls with endometriosis appear to be at higher risk for developing autoimmune diseases such as chronic fatigue syndrome, fibromyalgia, hypothyroidism, lupus, multiple sclerosis, rheumatoid arthritis, and Sjögren's syndrome. Currently, researchers are studying whether there is a greater risk for certain types of cancers. Because of these risks, and because symptoms seem to worsen with time, early diagnosis is important.

Like the lining of the uterus, endometrial growths usually respond to the hormones of the menstrual cycle, building up tissue and then breaking it down. The result is internal bleeding, inflammation of the surrounding areas, and formation of scar tissue and adhesions. Complications of endometriosis can include formation and even rupture of cysts (which can spread endometriosis to new areas), intestinal bleeding or obstruction, or interference with bladder function. Symptoms often worsen with time, though cycles of remission and recurrence are sometimes the pattern.

The extent or size of endometrial growths may not have any correlation with the intensity of pain. Even tiny growths can produce substances called prostaglandins that are involved in pain (as well as in menstrual cramps).

Endometrial growths (also referred to as
nodules, tumors, lesions, or implants) are usually inside the abdomen—on the ovaries, in the fallopian tubes, in the ligaments supporting the uterus, in the area between the vagina and the rectum, on the outer surface of the uterus, and on the lining of the pelvic cavity. The implants can also be found in internal abdominal surgery scars, or on the bladder, intestines, vagina, cervix, and vulva. Rarely, they develop in the lung, arm, thigh, and elsewhere in the body.

“Don't be a baby, honey; all girls get cramps. Take two aspirin and go back to class,” the nurse at my high school told me when I was bent over double in tears. . . . I'm not a baby. I'm not a hypochondriac. . . . It took six years to find out. Looking back, I wish I had been a more aggressive patient. I should never have allowed myself to believe these occurrences were all in my head. . . . Don't listen to the people who tell you to go away. Be persistent. Listen to your body
.

Endometriosis is a major factor in decreasing the quality of life for many girls and women. It can be chronic and its seriousness is often underestimated. The Endometriosis Association (endometriosisassn.org), an international self-help organization founded in 1980 that conducts research collaboratively with the National Institutes of Health and Vanderbilt University School of Medicine, has collected data from four thousand women diagnosed with endometriosis and found that 79 percent said that they were unable to carry on normal work and activities at times, yet 69 percent had been told by a gynecologist that nothing was wrong.

I was diagnosed too late, though I complained bitterly about very painful, heavy periods since my midteens. I think it's disgraceful that doctors aren't more interested in treating this disease before things get so out of hand. . . . I am 36 and too destroyed (physically and emotionally) to carry on the fight to preserve my fertility
.

Many doctors still don't take menstrual pain seriously. The average time between onset of symptoms and diagnosis is more than nine years because doctors are slow to diagnose and, in part, because girls and women delay reporting their symptoms. A compelling reason to push for earlier diagnosis is that those who had taken a long time to be diagnosed were more likely to end up having a hysterectomy, according to Endometriosis Association data.

A definitive diagnosis of endometriosis currently requires a laparoscopy—an outpatient surgical procedure done under anesthesia, in which the patient's abdomen is distended with carbon dioxide and the abdominal organs are checked by using a laparoscope (a fiber-optic tube with a light in it). Though growths can sometimes be detected during a manual pelvic exam or on ultrasound, endometriosis is sometimes confused with other disorders that have similar symptoms (PID, ectopic pregnancy, cysts, appendicitis, diverticulitis, irritable bowel
syndrome, or even cancer). The Endometriosis Association has a diagnostic kit that helps.

There are a number of treatments for endometriosis, but not one that works for everyone. The most important thing to know is that you must educate yourself and make your own decisions about your treatments, and find the right health care practitioner(s) for you. In the process, you may want to consider your age, your symptoms, where and how severe the growths are, whether or not you want to get pregnant, your past experiences with hormones, and family history.

Hormonal treatments aim to stop or stabilize the production of various hormones for as long as possible. Recently, aromatase inhibitors have also been used to stop estrogen production in lesions and in fat cells. Hormonal treatments include gonadotropin-releasing hormone (GnRH), agonists (such as Lupron), testosterone derivatives (danazol), progesterone-like drugs (Provera), the Mirena IUD (which releases a progestogen, a progesterone-like substance), and oral contraceptives. New drugs are currently in development. Medications can be very expensive, and all cause side effects that are problematic for some women. All tend to work while you are taking them, but the disease usually returns when you stop.

Surgery ranges from conservative (removing growths) to radical (hysterectomy and removal of the ovaries). Radical surgery has been called the definitive cure for endometriosis, but the disease can continue or recur even when the ovaries are removed with the uterus. Minimally invasive gynecologic surgery through the laparoscope has largely replaced major abdominal surgery. As with any surgery, the skill and experience of the surgeon are of paramount importance.