Pelvic inflammatory disease (PID) is the acute clinical manifestation of ascending genital-tract infection involving the endometrium, fallopian tubes, and/or adjacent pelvic structures.1Westrom L Mardh PA Acute pelvic inflammatory disease.in: Holmes KK Mardh PA Sparling PF Wiesner PJ Sexually transmitted diseases. 2nd ed. McGraw-Hill, New York1990: 593-613Google Scholar PID is a serious condition that almost exclusively affects sexually active women in their fertile years. Several million women worldwide have symptomatic PID each year, and a similar number probably have symptomless PID,2Wolner-Hansen P Kiviat NB Holmes KK Atypical pelvic inflammatory disease: subacute, chronic or subclinical upper genital tract infection in women.in: Holmes KK Mardh PA Sparling PF Wiesner PJ Sexually transmitted diseases. 2nd ed. McGraw-Hill, New York1990: 615-620Google Scholar and thus face an increased risk of infertility, ectopic pregnancy, and chronic pelvic pain.1Westrom L Mardh PA Acute pelvic inflammatory disease.in: Holmes KK Mardh PA Sparling PF Wiesner PJ Sexually transmitted diseases. 2nd ed. McGraw-Hill, New York1990: 593-613Google Scholar, 3Cates W Rolfs RT Aral SO Sexually transmitted diseases, pelvic inflammatory disease and infertility: an epidemiologic update.Epidemiol Rev. 1990; 12: 199-220PubMed Google Scholar, 4Hadgu A Koch G Westrom L Analysis of ectopic pregnancy data using marginal and conditional models.Stat Med. 1997; 16: 2403-2417Crossref PubMed Scopus (6) Google ScholarNo widely accepted clinical criteria exist for PID, which complicates diagnosis.1Westrom L Mardh PA Acute pelvic inflammatory disease.in: Holmes KK Mardh PA Sparling PF Wiesner PJ Sexually transmitted diseases. 2nd ed. McGraw-Hill, New York1990: 593-613Google Scholar, 5Hadgu A Westrom L Brook CA Reynolds GH Thompson SE Predicting acute pelvic inflammatory disease: A multivariate analysis.Am J Obstet Gynecol. 1986; 155: 954-960Summary Full Text PDF PubMed Scopus (48) Google Scholar, 6Kahn JG Walker CK Washington AE Landers DV Sweet RL Diagnosing pelvic inflammatory disease.in: A comprehensive analysis and consideration for developing a new model. JAMA. 266. 1991: 2594-2604Google Scholar Laparoscopic visualisation of inflamed fallopian tubes is considered the “gold standard” for diagnosis,7Jacobson L Westrom L Objectivized diagnosis of acute pelvic inflammatory disease.Am J Obstet Gynecol. 1969; 105: 1088-1098Summary Full Text PDF PubMed Scopus (361) Google Scholar though this technique has been found to miss some cases.8Sellors J Mahony J Goldsmith C et al.The accuracy of clinical findings and laparoscopy in pelvic inflammatory disease.Am J Obstet Gynecol. 1991; 164: 113-120Summary Full Text PDF PubMed Scopus (127) Google Scholar And, because of cost-containment and other reasons, laparoscopy is not available in many clinical situations. Incidence and prevalence rates, and trends therefore remain unknown. Studies based on hospital discharge surveys have found that at least 120–180 cases of acute PID per 10 000 women aged 15–24 years occur each year, with overall figures of 30–90 cases per 10 000 women aged 15–44 years.1Westrom L Mardh PA Acute pelvic inflammatory disease.in: Holmes KK Mardh PA Sparling PF Wiesner PJ Sexually transmitted diseases. 2nd ed. McGraw-Hill, New York1990: 593-613Google Scholar, 9Wright N Laemmle D Acute pelvic inflammatory disease in an indigent population.Am J Obstet Gynecol. 1968; 101: 979-990Summary Full Text PDF PubMed Scopus (64) Google Scholar, 10Westrom L Incidence, prevalence and trends of acute pelvic inflammatory disease and its consequences in industrialized countries.Am J Obstet Gynecol. 1980; 138: 880-892Summary Full Text PDF PubMed Scopus (572) Google Scholar In addition to the woman's morbidity, the costs of lost productivity and of hospital treatment are considerable, and include those for infertility, ectopic pregnancy, and chronic pelvic pain,11Curran J Economic consequences of pelvic inflammatory disease in the United States.Am J Obstet Gynecol. 1980; 138: 848-851Summary Full Text PDF PubMed Scopus (93) Google Scholar, 12Washington AE Katz P Cost and payment source for pelvic inflammatory disease: trends and projections, 1983 through 2000.JAMA. 1991; 266: 2565-2569Crossref PubMed Scopus (181) Google Scholar conditions that occur in about 20%, 9%, and 18% of women with syndromic PID, respectively.13Westrom L Joesoef R Reynolds G Hadgu A Thompson SE Pelvic inflammatory disease and infertility.in: A cohort study of 1844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sex Transm Dis. 19. 1992: 185-192Google ScholarWomen treated in hospital for PID increased in many European countries during the 1960s and 1970s,10Westrom L Incidence, prevalence and trends of acute pelvic inflammatory disease and its consequences in industrialized countries.Am J Obstet Gynecol. 1980; 138: 880-892Summary Full Text PDF PubMed Scopus (572) Google Scholar, 14Adler MW Trends for gonorrhea and pelvic inflammatory disease in England and Wales and for gonorrhea in a defined population.Am J Obstet Gynecol. 1980; 138: 901-904PubMed Scopus (12) Google Scholar and paralleled the epidemics of gonorrhoea and genital-tract chlamydial infection that began in the early 1960s. Although acute PID can have a polymicrobial aetiology,15Eschenbach DA Buchanan TM Pollock HM et al.Polymicrobial etiology of acute pelvic inflammatory disease.N Engl J Med. 1975; 293: 166-171Crossref PubMed Scopus (359) Google Scholar, 16Sweet RL Draper DL Hadley WK Etiology of acute salpingitis: influence of episode, number and duration of symptoms.Obstet Gynecol. 1981; 58: 62-68PubMed Google Scholar, 17Hemsell DL Nobles BJ Heard MC Hemsell PG Upper and lower reproductive tract bacteria in 126 women with acute pelvic inflammatory disease.in: Microbial susceptibility and clinical response to four therapeutic regimens. J Reprod Med. 33. 1988: 799-805Google Scholar it is the most common and most serious complication of genital chlamydial and gonococcal infections–the main cause of PID in about 80% of cases in women younger than 25 years.1Westrom L Mardh PA Acute pelvic inflammatory disease.in: Holmes KK Mardh PA Sparling PF Wiesner PJ Sexually transmitted diseases. 2nd ed. McGraw-Hill, New York1990: 593-613Google Scholar Strategies to detect, treat, and prevent lower genital-tract chlamydial and gonococcal infections are essential measures to reduce both symptomatic and clinically silent PID.The Swedish experienceUnder Swedish law, gonorrhoea and syphilis have been reportable as contagious diseases since 1919. Genital infection with Chlamydia trachomatis has been reported by diagnostic laboratories since 1982, and was made a notifiable disease in April, 1988.18Ripa T Epidemiologic control of genital Chlamydia trachomatis infections.Scand J Infect Dis Suppl. 1990; 69: 157-167PubMed Google Scholar This change in the law was preceded by intense discussions over the pros and cons, but because of the emerging HIV epidemic, the argument prevailed that treatable gonococcal and chlamydial infections could be used as realistic opportunities to counsel young people about sexually transmitted diseases (STDs), including HIV. Furthermore, genital chlamydial infection was established in the 1970s as an important aetiological agent of PID.19Eilard T Brorson JE Hamark B Forsman L Isolation of Chlamydia in acute salpingitis.Scand J Infect Dis Suppl. 1976; 9: 82-84PubMed Google Scholar, 20Mardh PA Ripa T Svensson L Westrom L Chlamydia trachomatis infection in patients with acute salpingitis.N Engl J Med. 1977; 296: 1377-1379Crossref PubMed Scopus (313) Google ScholarAvailable figures on the incidence rates of gonorrhoea and genital chlamydial infections have helped determine the relation between these infections and the annual number of patients admitted to hospital for PID.21Forslin L Falk V Danielsson D Changes in the incidence of acute gonococcal and nongonococcal salpingitis: a five-year study from an urban area of central Sweden.Br J Vener Dis. 1978; 54: 247-250PubMed Google Scholar, 22Ripa T Forslin L Danielsson D Falk V Frequency of gonococcal and chlamydial infections in patients with laparoscopically verified acute salpingitis in 1970 and 1980; epidemiological considerations.in: Mardh PA Holmes KK Oriel JD Piot P Schachter J Chlamydial Infections. Elsevier Biomedical Press, Amsterdam1982: 179-182Google Scholar, 23Westrom L Svensson L Wolner-Hansen P Mardh PA Chlamydial and gonococcal infections in a defined population of women.Scand J Infect Dis Suppl. 1982; 32: 157-162PubMed Google Scholar, 24Kamwendo F Forslin L Bodin L Danielsson D Decreasing incidences of gonorrhea- and chlamydia-associated acute pelvic inflammatory disease.in: A 25-year study from an urban area of central Sweden. Sex Transm Dis. 23. 1996: 384-391Google Scholar, 25Kamwendo F Forslin L Danielsson D Epidemiology and aetiology of acute non-tuberculous salpingitis: a comparison between the early 1970s and the early 1980s with special reference to gonorrhoea and use of intrauterine contraceptive device.Genitourin Med. 1990; 66: 324-329PubMed Google Scholar, 26Westrom L Bengtsson LP Mardh PA The risk of pelvic inflammatory disease in women using intrauterine contraceptive devices as compared to non-users.Lancet. 1976; ii: 221-224Summary Scopus (176) Google Scholar, 27Lee NC Rubin GL Borucki R The intrauterine device and pelvic inflammatory disease revisited: new results from the women's health study.Obstet Gynecol. 1988; 72: 1-6PubMed Google Scholar, 28Kihlstrom E Danielsson D Advances in biology, management and prevention of infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae.Curr Opin Infect Dis. 1994; 7: 25-33Crossref Scopus (13) Google Scholar This relation is further illustrated by comparison of a 1970–97 study of patients hospitalised at our centre for acute PID (figure 1), with incidence rates of gonorrhoea and genital chlamydia in the community (figure 2). The county of Örebro, with a mixed urban and rural population, is representative of a demographic cross section of Sweden for yearly incidence rates of gonorrhoea and genital chlamydia (figure 2). Thus, our long-term PID study may reflect the situation throughout Sweden.Figure 2Incidence of acute PID by age group in Örebro Medical Centre Hospital catchment area per 5-year periodShow full captionFinal data points are for 1995–96. Inset shows national and Örebro county incidence rates of lower genital-tract N gonorrhoeae (Ng) and C trachomatis (Ct) infectionsView Large Image Figure ViewerDownload Hi-res image Download (PPT)In the 28-year period represented in figure 1, almost 2650 patients were recruited from the same catchment area. The diagnostic criteria used were similar throughout the period.21Forslin L Falk V Danielsson D Changes in the incidence of acute gonococcal and nongonococcal salpingitis: a five-year study from an urban area of central Sweden.Br J Vener Dis. 1978; 54: 247-250PubMed Google Scholar, 24Kamwendo F Forslin L Bodin L Danielsson D Decreasing incidences of gonorrhea- and chlamydia-associated acute pelvic inflammatory disease.in: A 25-year study from an urban area of central Sweden. Sex Transm Dis. 23. 1996: 384-391Google Scholar Confirmation by laparoscopy was made in 60–65% of cases in the 1970s and 1980s, but, because of cost-containment policies, this procedure was used only in questionable cases in the 1990s. The diagnostic criteria used correspond well with those proposed, discussed, and analysed in other publications.5Hadgu A Westrom L Brook CA Reynolds GH Thompson SE Predicting acute pelvic inflammatory disease: A multivariate analysis.Am J Obstet Gynecol. 1986; 155: 954-960Summary Full Text PDF PubMed Scopus (48) Google Scholar, 6Kahn JG Walker CK Washington AE Landers DV Sweet RL Diagnosing pelvic inflammatory disease.in: A comprehensive analysis and consideration for developing a new model. JAMA. 266. 1991: 2594-2604Google Scholar, 8Sellors J Mahony J Goldsmith C et al.The accuracy of clinical findings and laparoscopy in pelvic inflammatory disease.Am J Obstet Gynecol. 1991; 164: 113-120Summary Full Text PDF PubMed Scopus (127) Google ScholarIn a discussion of effective programmes to reduce PID, our long-term study may serve to illustrate certain issues, including: factors that influence PID epidemiology, antibiotic treatment, and the role of the male sex partner.Role of the intrauterine contraceptive device (IUCD)In our study, the number of patients admitted to hospital with PID varied less than 16% from year to year in the early 1970s and 1980s, by contrast with an almost 75% increase in the mid-1970s (figure 1). This increase mainly resulted from an indiscriminate use of IUCDs in young, sexually active, nulliparous women;25Kamwendo F Forslin L Danielsson D Epidemiology and aetiology of acute non-tuberculous salpingitis: a comparison between the early 1970s and the early 1980s with special reference to gonorrhoea and use of intrauterine contraceptive device.Genitourin Med. 1990; 66: 324-329PubMed Google Scholar findings that agree with those of others.26Westrom L Bengtsson LP Mardh PA The risk of pelvic inflammatory disease in women using intrauterine contraceptive devices as compared to non-users.Lancet. 1976; ii: 221-224Summary Scopus (176) Google Scholar, 27Lee NC Rubin GL Borucki R The intrauterine device and pelvic inflammatory disease revisited: new results from the women's health study.Obstet Gynecol. 1988; 72: 1-6PubMed Google Scholar The majority of infections related to use of IUCDs were not associated with STDs but were caused by ascending indigenous vaginal flora (unpublished data). A national consensus was reached that IUCDs should not be prescribed to sexually active, nulliparous women. Subsequently, the number of PID cases fell to previous figures.Epidemiology of gonococcal and chlamydial PIDThe incidence of gonorrhoea peaked in Sweden in 1970 with an annual incidence of almost 500 per 100 000 population. Since then, incidence has steadily declined in both women and men, and endemic gonorrhoea has now been eradicated in Sweden.28Kihlstrom E Danielsson D Advances in biology, management and prevention of infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae.Curr Opin Infect Dis. 1994; 7: 25-33Crossref Scopus (13) Google Scholar Cases diagnosed today are usually imported.In the late 1960s, and in 1970 when the gonorrhoea epidemic peaked, 40–45% of patients had gonococcal PID (figure 1),21Forslin L Falk V Danielsson D Changes in the incidence of acute gonococcal and nongonococcal salpingitis: a five-year study from an urban area of central Sweden.Br J Vener Dis. 1978; 54: 247-250PubMed Google Scholar, 24Kamwendo F Forslin L Bodin L Danielsson D Decreasing incidences of gonorrhea- and chlamydia-associated acute pelvic inflammatory disease.in: A 25-year study from an urban area of central Sweden. Sex Transm Dis. 23. 1996: 384-391Google Scholar and 15–17% of women with untreated gonorrhoea developed acute PID. These figures changed substantially during the 1970s; the decline of gonococcal PID coincided with the falling incidence of gonorrhoea in the community (figure 2). In fact, the incidence of gonococcal PID decreased proportionately further than that of urogenital gonorrhoea, which suggests that the decrease of gonorrhoea was real, and also that improved control of gonorrhoea in the community will result in a relatively greater decline in gonococcal PID. The results of our study support these suggestions: community gonorrhoea increased slightly both nationally and locally in Örebro county in the mid-1970s (figure 2), and corresponded to a local increase in gonococcal PID (figure 1).Despite the obvious decrease of gonococcal PID, the total number of patients hospitalised for PID did not change during the 1970s and early 1980s after exclusion of those related to IUCDs. A retrospective seroepidemiological study has shown that cases of PID due to chlamydia, an organism that was unknown at the time, were at least as common as gonococcal PID.22Ripa T Forslin L Danielsson D Falk V Frequency of gonococcal and chlamydial infections in patients with laparoscopically verified acute salpingitis in 1970 and 1980; epidemiological considerations.in: Mardh PA Holmes KK Oriel JD Piot P Schachter J Chlamydial Infections. Elsevier Biomedical Press, Amsterdam1982: 179-182Google Scholar The extent of community genital chlamydial infections soon became obvious after introduction of improved culture and antigen-detection techniques for diagnosis.18Ripa T Epidemiologic control of genital Chlamydia trachomatis infections.Scand J Infect Dis Suppl. 1990; 69: 157-167PubMed Google Scholar, 28Kihlstrom E Danielsson D Advances in biology, management and prevention of infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae.Curr Opin Infect Dis. 1994; 7: 25-33Crossref Scopus (13) Google Scholar Screening strategies were adopted at family planning clinics, outpatient contraception clinics, antenatal clinics, &c. Identification and screening of symptom-free men were facilitated by the option to use urine samples.Genital chlamydial infections in the community continuously declined as much as 65–75% after 1987 (figure 2). This decline coincided with a decrease in hospital-treated PID cases (figures 1 and 29Westrom L Decrease in incidence of women treated in hospital for acute salpingitis in Sweden.Genitourin Med. 1988; 64: 59-63PubMed Google Scholar). Today, incidence rates are only 25% of those in the early 1970s and 1980s. However, patients hospitalised for PID in Sweden and other countries probably represent the most severe cases. A fall in hospital-treated PID cases in the USA during the late 1980s and early 1990s has been interpreted to reflect changes in aetiology (an increasing proportion of more indolent chlamydial-associated PID) and clinical management (from inpatient to outpatient) rather than true trends in disease incidence.30Division of STD Prevention Sexually Transmitted Disease Surveillance, 1996. Centers for Disease Control and Prevention, Atlanta1997Google Scholar In Sweden, the admission to hospital of young women with suspected PID to minimise sequelae has been encouraged through continuing medical education. We cannot exclude, however, that the cost-containment policies and managed care implemented in Sweden in the mid-1990s may have had an impact on the number of hospital-treated PID patients over the past few years.Antibiotic treatmentEffective antibiotic treatment of patients with PID is essential. Treatment must be started early, preferably within 2 days of the onset of abdominal pain, to avoid the serious sequelae of tubal infertility and ectopic pregnancy.3Cates W Rolfs RT Aral SO Sexually transmitted diseases, pelvic inflammatory disease and infertility: an epidemiologic update.Epidemiol Rev. 1990; 12: 199-220PubMed Google Scholar, 4Hadgu A Koch G Westrom L Analysis of ectopic pregnancy data using marginal and conditional models.Stat Med. 1997; 16: 2403-2417Crossref PubMed Scopus (6) Google Scholar However, most patients with PID delay in seeking medical care because of vague symptoms, which is especially true for women with chlamydial disease. Although most PID patients younger than 25 years of age may have a gonococcal and/or chlamydial infection, these women and especially women older than 25 years may have polymicrobial PID with microorganisms of the indigenous vaginal flora.15Eschenbach DA Buchanan TM Pollock HM et al.Polymicrobial etiology of acute pelvic inflammatory disease.N Engl J Med. 1975; 293: 166-171Crossref PubMed Scopus (359) Google Scholar, 16Sweet RL Draper DL Hadley WK Etiology of acute salpingitis: influence of episode, number and duration of symptoms.Obstet Gynecol. 1981; 58: 62-68PubMed Google Scholar, 17Hemsell DL Nobles BJ Heard MC Hemsell PG Upper and lower reproductive tract bacteria in 126 women with acute pelvic inflammatory disease.in: Microbial susceptibility and clinical response to four therapeutic regimens. J Reprod Med. 33. 1988: 799-805Google Scholar Broad-spectrum antimicrobial treatment is therefore essential, with a tetracycline plus a third-generation cephalosporin, plus metronidazole if an anaerobic abscess is suspected. This and similar schedules are recommended by the US Centers for Disease Control and Prevention31Centers for Disease Control and Prevention 1998 guidelines for treatment of sexually transmitted diseases.MMWR Morb Mortal Wkly Rep. 1998; 46: 79-85Google Scholar This regimen has been successfully used at our hospital since the mid-1970s. Recurrence rates were much lower in our centre24Kamwendo F Forslin L Bodin L Danielsson D Decreasing incidences of gonorrhea- and chlamydia-associated acute pelvic inflammatory disease.in: A 25-year study from an urban area of central Sweden. Sex Transm Dis. 23. 1996: 384-391Google Scholar than those reported from another centre where treatment with tetracycline alone was given.3Cates W Rolfs RT Aral SO Sexually transmitted diseases, pelvic inflammatory disease and infertility: an epidemiologic update.Epidemiol Rev. 1990; 12: 199-220PubMed Google ScholarThe male sexual partnerIn countries with legislation to control gonorrhoea, contact tracing and notification of the male sex partner(s) of a woman with gonococcal PID is usually mandatory. In our hospital, 40–45% of all patients treated for PID in the late 1960s and early 1970s had gonococcal disease.21Forslin L Falk V Danielsson D Changes in the incidence of acute gonococcal and nongonococcal salpingitis: a five-year study from an urban area of central Sweden.Br J Vener Dis. 1978; 54: 247-250PubMed Google Scholar However, male partners were not usually contacted by the STD outpatient clinic until after the patient was discharged from hospital. Thus, the opportunity was often missed to counsel and inform both patient and partners and to treat partners promptly while the patient was still in hospital. In a joint study in the mid-1980s of patients with gonococcal or chlamydial PID referred from various sources, we found that about two-thirds of male partners had a urethritis that was verified as gonococcal, chlamydial, or non-gonococcal/non-chlamydial urethritis.32Johansson E Moi H Forslin L Danielsson D Prevalence of chlamydia infection, gonorrhoea and nonspecific urethritis in regular sexual partners of women with acute salpingitis.in: VII International Meeting of the International Society for STD Research, Atlanta, GA, USA 1987Google Scholar, 33Kamwendo F Johansson E Moi H Forslin L Danielsson D Gonorrhea, genital chlamydial infection and nonspecific urethritis in male partners of women hospitalized for acute pelvic inflammatory disease.Sex Transm Dis. 1993; 20: 143-146Crossref PubMed Scopus (24) Google Scholar We also found that, even if a woman with PID thought she had a monogamous sexual relationship, this was not always so for her male partner. From then, our policy has been prompt notification of partners for examination, treatment, information, and counselling while the patient is in hospital. The recurrence rate of PID has decreased in patients whose partners were managed in this way.24Kamwendo F Forslin L Bodin L Danielsson D Decreasing incidences of gonorrhea- and chlamydia-associated acute pelvic inflammatory disease.in: A 25-year study from an urban area of central Sweden. Sex Transm Dis. 23. 1996: 384-391Google Scholar This and other similar studies34Sellors J Mahony JB Chernesky MA Groves DJ Rath DJ Male contact tracing in a community-based study of confirmed acute pelvic inflammatory disease.in: VII International Meeting of the International Society of STD Research, Atlanta, GA, USA 1987Google Scholar show that consideration of both the patient and her partner is an essential element in the management of PID.Prevention strategiesMeasures being used or recommended for the prevention of PID will differ between countries because medical and cultural/social practices, ethical, legal, and economic factors must be considered. Although reduction and prevention of gonococcal and chlamydial infections are probably the most productive steps in prevention of PID, these pathogens cannot be found in about one-third of PID cases, in which the indigenous flora of the genital tract (mycoplasmas, anaerobes, enterobacteria, &c) may be implicated. Washington et al35Washington AE Cates Jr, W Wasserheit JN Preventing pelvic inflammatory disease.JAMA. 1991; 266: 2574-2580Crossref PubMed Scopus (33) Google Scholar did a comprehensive literature search to identify effective strategies for PID prevention, and examined relevant data on primary, secondary, and tertiary prevention.Primary prevention involves strategies to help individuals avoid exposure to infection with the two most important pathogens–Neisseria gonorrhoeae and Chlamydia trachomatis. Washington et al35Washington AE Cates Jr, W Wasserheit JN Preventing pelvic inflammatory disease.JAMA. 1991; 266: 2574-2580Crossref PubMed Scopus (33) Google Scholar analysed a wide range of suggested measures, such as “healthy” sexual behaviour (delayed sexual debut, reduced number of sexual partners, monogamous relationships, &c), and the use of mechanical and chemical barrier methods. They found that the long-term efficacy of these and other preventive measures had not been properly evaluated. They concluded, however, that increased public concern over HIV infection had had an impact on primary prevention. In fact, the decline in incidence of PID and in referrals of STDs reported from the Netherlands was ascribed to a change of heterosexual behaviour in the era of HIV/AIDS.36Coutinho RA Rijsdijk AJ van den Hoek JAR Leentvaar-Kuijpers A Decreasing incidence of PID in Amsterdam.Genitourin Med. 1992; 68: 353-355PubMed Google ScholarSecondary prevention involves keeping a lower genital-tract infection from either ascending to the upper genital tract or being further transmitted within the community. However, about 50% of women with gonococcal infections and 60–70% of those with chlamydial infections are symptom-free. These infections might be detected through partner notification by infected men but targeted screening programmes are more preferable. In Sweden, such programmes seem to have been successful in the eradication of endemic gonorrhoea, and in significantly reducing chlamydial infection,28Kihlstrom E Danielsson D Advances in biology, management and prevention of infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae.Curr Opin Infect Dis. 1994; 7: 25-33Crossref Scopus (13) Google Scholar which will have contributed to PID prevention, particularly in women younger than 25 years (figure 2). Direct evidence that a screening programme for chlamydial infection in women can contribute to the secondary prevention of PID was provided by Scholes et a1.37Scholes D Stergachis A Heidrich FE Andrilla H Holmes KK Stamm WE Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection.N Engl J Med. 1996; 334: 1362-1366Crossref PubMed Scopus (775) Google Scholar In a randomised, controlled trial of selective testing for cervical chlamydial infection, the incidence of PID was reduced by more than 50%.Tertiary prevention, as defined by Washington et al35Washington AE Cates Jr, W Wasserheit JN Preventing pelvic inflammatory disease.JAMA. 1991; 266: 2574-2580Crossref PubMed Scopus (33) Google Scholar involves preventing complications of upper-genital-tract infection, such as tubal dysfunction and/or obstruction. Early effective antibiotic treatment to maintain tubal patency is emphasised by these authors and others.15Eschenbach DA Buchanan TM Pollock HM et al.Polymicrobial etiology of acute pelvic inflammatory disease.N Engl J Med. 1975; 293: 166-171Crossref PubMed Scopus (359) Google Scholar, 16Sweet RL Draper DL Hadley WK Etiology of acute salpingitis: influence of episode, number and duration of symptoms.Obstet Gynecol. 1981; 58: 62-68PubMed Google Scholar, 17Hemsell DL Nobles BJ Heard MC Hemsell PG Upper and lower reproductive tract bacteria in 126 women with acute pelvic inflammatory disease.in: Microbial susceptibility and clinical response to four therapeutic regimens. J Reprod Med. 33. 1988: 799-805Google Scholar, 31Centers for Disease Control and Prevention 1998 guidelines for treatment of sexually transmitted diseases.MMWR Morb Mortal Wkly Rep. 1998; 46: 79-85Google Scholar The vague symptoms associated with chlamydial PID, however, often mean delay in seeking medical care and, thus, an increased risk of late sequelae. Gonococcal PID seems to have a more acute clinical course, which usually leads the patient to seek emergency treatment early. Falk,38Falk V Treatment of acute non-tuberculous salpingitis with antibiotics alone and in combination with glucocorticoids.Acta Obstet Gynecol Scand. 1965; 44: 1-118Crossref Scopus (70) Google Scholar in his comprehensive study of non-tuberculous acute salpingitis in the early 1960s, showed that women with gonococcal PID had a significantly better fertility prognosis than those with non-gonococcal PID.ConclusionsPrimary, secondary, and tertiary prevention strategies are all important to reduce PID and its sequelae. Counselling, education, and information campaigns, directed at both society as a whole and the individual to increase awareness of the consequences of sexual risk behaviour, can be combined with targeted screening programmes. Early and effective antibiotic treatment of PID will reduce adverse effects on tubal patency, and inclusion of male sexual partners in management will re

BACKGROUND AND OBJECTIVES:Acute pelvic inflammatory disease (PID) affects women in their reproductive years and is often a complication of a sexually transmitted disease (STD), particularly Neisseria gonorrhoeae and Chlamydia trachomatis. Infertility, ectopic pregnancy, and chronic lower abdominal pain are common long-term sequelae to acute PID. Through different preventive measures, endemic N. gonorrhoeae is almost eliminated, and C. trachomatis has been reduced almost fourfold in Sweden. GOALS:To investigate variations in STD-associated acute PID and the extent to which this influenced the yearly incidences of patients hospitalized for this complication during a 25-year-period. STUDY DESIGN:Hospital records of 2499 patients admitted and treated for acute PID from January 1, 1970 to December 31, 1994 were analyzed for infection with N. gonorrhoeae. Routine laboratory diagnosis for C. trachomatis infection started June 1, 1980. Detailed statistical analysis for chlamydial-associated PID in this study, therefore, covers the period January 1, 1981 to December 31, 1994 and includes 1030 patients. RESULTS:Gonorrhea occurred in 42% of patients with acute PID in 1970 and decreased continuously to zero in 1988 and beyond. Concomitant urogenital chlamydial infection reduced almost fourfold from 28.4% in 1985 to 7.7% in 1994. Yearly admissions for acute PID fluctuated slightly (< or = 16%) in the early 1970s and early 1980s but increased greatly (> 60%) in the middle and late 1970s; the highest was 180 per year in 1976. This coincided with high incidence rates of gonorrhea in the general population, and probably of genital C. trachomatis infection as well, coupled with an increased use of intrauterine contraceptive device in nulliparous women. The largest increase in admissions for acute PID was in the 15- to 29-year-old group. A steady decrease started in 1987 and reached the low figure of 26 admissions in 1994. The greatest decrease occurred in the 15- to 19-year-old group, from the relative age distribution of 28.9% in the period 1970 to 1974 to 12.9% in 1990 to 1994. Yearly admissions for the > or = 35-year-old group remained almost constant during the study period, but the relative age distribution shifted from second lowest (excluding those 14 years or younger, totaling 15 admissions for the entire study period), 9.1% at the beginning of the study period, to the second largest, 24.9% at the end of it. The study also showed that the total and relative rates of recurrence decreased. CONCLUSIONS:Measures aimed at reducing incidences of gonorrhea and genital chlamydial infection will reduce the incidences of one of the most serious complications of these STDs, acute PID, and, in turn, its long-term sequelae.