Pharmacist Counseling Can Impact Treatment and Prevention of Pelvic Inflammatory Disease

Pharmacist Counseling Can Impact Treatment and Prevention of Pelvic Inflammatory Disease

The Centers for Disease Control and Prevention (CDC) report that 1 million cases of pelvic inflammatory disease (PID) are diagnosed every year, making it the most common gynecologic infection in the United States.1 One of the most important statistics is this—20 percent of the patients are adolescents. In fact, the greatest risk factor for PID is being a female between the ages of 15 to 20 years. In this age group, about 18 percent don’t use any form of birth control. Of those who use contraceptives, only half use a condom.2
Chlamydia is the most common sexually transmitted infection, followed by gonorrhea. It’s estimated that 10 to 20 percent of untreated chlamydial or gonorrheal infections progress to PID, but other bacteria are increasingly identified as causative pathogens.3 No matter which pathogen is to blame, PID frequently goes unrecognized, so women go untreated. Intervention to promote awareness and encourage treatment can prevent these common complications:

  • Chronic pelvic pain – Estimated to occur in about 25 percent of patients.
  • Chronic abdominal pain – One study found that nearly 43 percent of adolescents had chronic abdominal pain when they were followed for 84 months following a PID diagnosis.4
  • Infertility – Infection and inflammation cause scarring and adhesions that impair the ability to conceive in at least 19 percent of patients. About half of all women with tubal factor infertility have scarring and antibodies to Chlamydia trachomatis even if they were never aware of having PID.
  • Ectopic pregnancy – Women with a history of PID have a 15 to 50 percent higher risk of ectopic pregnancy due to fallopian tube damage.
  • Tubo-ovarian abscess – Occurs in one-third of the women hospitalized for PID. This requires aggressive treatment with antibiotics and/or surgery to prevent peritonitis and sepsis.

Pharmacist Counseling Can Impact Treatment and Prevention of Pelvic Inflammatory Disease

There’s no doubt about it—many people have a hard time talking about sexually transmitted infections like pelvic inflammatory disease. Even parents who talk with their children about sex admit they don’t generally get into tough issues like STDs. But this lack of communication comes at a high cost for women, potentially leading to chronic pelvic pain and infertility.

Open communication is made more urgent by the fact that pelvic inflammatory disease often goes unrecognized and, consequently, untreated. So don’t be tempted to shy away from a difficult topic. The reproductive health of many women, especially young women, depends on pharmacists who care enough to take the lead and promote education and awareness.

Overview of Pelvic Inflammatory Disease

The Centers for Disease Control and Prevention (CDC) report that 1 million cases of pelvic inflammatory disease (PID) are diagnosed every year, making it the most common gynecologic infection in the United States.1 One of the most important statistics is this—20 percent of the patients are adolescents. In fact, the greatest risk factor for PID is being a female between the ages of 15 to 20 years. In this age group, about 18 percent don’t use any form of birth control. Of those who use contraceptives, only half use a condom.2

Chlamydia is the most common sexually transmitted infection, followed by gonorrhea. It’s estimated that 10 to 20 percent of untreated chlamydial or gonorrheal infections progress to PID, but other bacteria are increasingly identified as causative pathogens.3 No matter which pathogen is to blame, PID frequently goes unrecognized, so women go untreated. Intervention to promote awareness and encourage treatment can prevent these common complications:

  • Chronic pelvic pain – Estimated to occur in about 25 percent of patients.
  • Chronic abdominal pain – One study found that nearly 43 percent of adolescents had chronic abdominal pain when they were followed for 84 months following a PID diagnosis.4
  • Infertility – Infection and inflammation cause scarring and adhesions that impair the ability to conceive in at least 19 percent of patients. About half of all women with tubal factor infertility have scarring and antibodies to Chlamydia trachomatis even if they were never aware of having PID.
  • Ectopic pregnancy – Women with a history of PID have a 15 to 50 percent higher risk of ectopic pregnancy due to fallopian tube damage.
  • Tubo-ovarian abscess – Occurs in one-third of the women hospitalized for PID. This requires aggressive treatment with antibiotics and/or surgery to prevent peritonitis and sepsis.

Difficult Diagnosis and the Case for Empiric Treatment

Pelvic inflammatory disease is difficult to diagnose because symptoms are nonexistent in about 60 percent of cases. In others, they’re mild and nonspecific. Onset can also be acute, in which case women present with fever, nausea, vomiting and severe pelvic pain. General symptoms include:

  • Pain in the lower abdomen – the most common symptom
  • Vaginal discharge
  • Fever
  • Painful sex
  • Pain when urinating
  • Irregular menstrual periods
  • Pain in upper abdomen – only caused by a rare complication called Fitz-Hugh-Curtis syndrome

The CDC strongly recommends a low threshold for aggressive patient treatment, preferring overtreatment to delayed treatment. All sexually active women younger than 25, and other women at risk for STIs, should be empirically treated if they meet the following guidelines:

  • Presence of pelvic or lower abdominal pain
  • No other illness identified
  • One or more of the following on examination – cervical motion tenderness, uterine tenderness or adnexal tenderness

Treatment regimens must be effective against N. gonorrhoeae and C. trachomatis, but should include broad-spectrum coverage. In addition to a long list of potential pathogens, a study published in Sexually Transmitted Infections in September 2016 reported an association between PID and four new bacteria: S. sanguinegens, S. amnionii, A. vaginae and BVAB1.9

For mild to moderate PID, a combined intramuscular/oral regimen is effective, but if patients don’t respond within 72 hours, they should be reevaluated and considered for intravenous therapy. The CDC recommends two outpatient regimens:10

Regimen A:

  • Ceftriaxone 250 mg intramuscularly once as a single dose plus
  • Doxycycline 100 mg orally twice daily for 14 days with or without
  • Metronidazole 500 mg orally twice daily for 14 days

Regimen B:

  • Cefoxitin 2 g IM once as a single dose and
  • Probenecid 1 g orally in a single dose plus
  • Doxycycline 100 mg orally twice daily for 14 days with or without
  • Metronidazole 500 mg orally twice daily for 14 days

Approach to Patient Counseling for Pharmacists

Patients who have been to the doctor need information about their prescriptions and advice for avoiding adverse events, like wearing a sunscreen while taking doxycycline to avoid a photosensitivity reaction. When you offer medication counseling, give them a handout about PID and remind them how critical it is to take their medication and get regular exams to avoid long-term complications like infertility.

In the case of patients who don’t yet realize they may have PID and have not been formally diagnosed, you must be particularly sensitive. You can’t reach out to them directly, yet they’re most in need of intervention. Consider these ideas to raise awareness:

  • Schedule health education: Ask a health educator from a local family planning agency, an OB/GYN nurse practitioner, or a gynecologist to host an information session at your pharmacy. It could be informal and allow patients to drop in with questions. It may also include a formal talk about PID. However, don’t coordinate this type of service unless you’re prepared to promote the event properly.
  • Put information in contraceptive sections: Create posters to display in the women’s birth control and condom sections of your pharmacy. Use eye-catching messages that focus on concepts like PID being a silent or hidden disease that causes infertility. Another good message for younger patients is, “If you skipped using a condom—even once—you may have PID.” Be sure the poster tells them to “ask the pharmacist.”
  • Be prepared with handouts: The CDC has print versions of PID information you can use. A local family planning clinic may have extra pamphlets they’ll share. Make a list of key local resources to give along with the handout. Be sure to clearly identify your pharmacy and provide your contact information on all handouts. Ask checkout staff to give handouts to anyone purchasing contraceptives.

Outreach to Promote Prevention of PID

When it comes to prevention, the message is simple—abstain from sex, have one regular partner who is free of infection, or use a condom. If you don’t have the opportunity to talk about prevention, this makes another good message to put on a poster. Beyond educating about prevention, it’s vital for pharmacists to help young women get early treatment because that’s the only way to prevent long-term sequelae. Any creative outreach that gets the message across stands to improve a woman’s life.

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Show 10 footnotes

  1. “Pelvic Inflammatory Disease: Strategies for Treatment and Prevention,” September 2016, https://www.uspharmacist.com/article/pelvic-inflammatory-disease-strategies-for-treatment-and-prevention
  2. “Contraceptive Use in the United States,” September 2016, https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states
  3. “Pelvic Inflammatory Disease,” September 2015, http://emedicine.medscape.com/article/256448-overview
  4. “Adverse Adolescent Reproductive Health Outcomes After Pelvic Inflammatory Disease,” January 2011, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415857/
  5. “Pelvic Inflammatory Disease: Strategies for Treatment and Prevention,” September 2016, https://www.uspharmacist.com/article/pelvic-inflammatory-disease-strategies-for-treatment-and-prevention
  6. “Contraceptive Use in the United States,” September 2016, https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states
  7. “Pelvic Inflammatory Disease,” September 2015, http://emedicine.medscape.com/article/256448-overview
  8. “Adverse Adolescent Reproductive Health Outcomes After Pelvic Inflammatory Disease,” January 2011, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415857/
  9. “Identification of Novel Microbes Associated with Pelvic Inflammatory Disease and Infertility,” September 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5013099/
  10. “Pelvic Inflammatory Disease,” June 2015, http://www.cdc.gov/std/tg2015/pid.htm
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