Current perspectives in the USA on the diagnosis and treatment of pelvic inflammatory disease in adolescents

Causal Relationship Between Endometriosis and Pelvic Inflammatory Diseases: Mendelian Randomization Study

Objective

This study explores the causal relationship between endometriosis and pelvic inflammatory diseases (PID).

Methods

The study utilized genome-wide association study (GWAS) datasets for endometriosis ("finn-b-N14_ENDOMETRIOSIS") and PID ("finn-b-N14_OTHFEMPELINF"). Subsequently, two-sample Mendelian randomization (MR) analyses were conducted using inverse variance weighting (IVW), Egger regression (MR-Egger), and weighted median (WM) methods. Heterogeneity was evaluated using Cochran's Q test, and in case of detected outliers, they were removed for re-evaluation of MR causality.

Results

From the endometriosis GWAS dataset, 33 single nucleotide polymorphisms (SNPs) were selected as instrumental variables. All three methods, IVW (OR = 1.39, P < 1×10-8), MR-Egger (OR = 1.41, P = 0.003), and WM (OR = 1.37, P = 1.16×10-5) confirmed a causal relationship between endometriosis and PID. The association between endometriosis and pelvic inflammation remained unaffected by the exclusion of individual SNPs. Lastly, Cochran's Q test and funnel plots showed no evidence of SNP asymmetry.

Conclusion

The results of the MR analysis support a potential causal relationship between endometriosis and an increased risk of PID.

An Adolescent Female With Acute Abdominal Pain: A Rare Case in Pediatrics

We present the case of a 13-year-old female with a 48-hour history of diffuse abdominal pain, fever, nausea, and vomiting, with worsening in the last few hours. On examination, she had signs of acute abdomen, and laboratory tests showed elevated acute phase reactants (APR). Abdominal ultrasound excluded acute appendicitis. A history of risky sexual behavior was reported, so pelvic inflammatory disease (PID) was considered. Although appendicitis is the most common cause of acute abdomen in adolescents, PID should be suspected in adolescents with risk factors. Prompt treatment is necessary to avoid possible complications and sequelae.

Kangfuxiaoyanshuan alleviates uterine inflammation and adhesion via inhibiting NF-κB p65 and TGF-β/MMP-2 signaling pathway in pelvic inflammatory disease rats

Background and aims: Pelvic inflammatory disease (PID) is infection-induced inflammation of the female upper reproductive tract that results in high fever, ectopic pregnancy, infertility, and varying degrees of chronic pelvic pain. Recent clinical studies have shown that Kangfuxiaoyanshuan (KFXYS), a Traditional Chinese Medicine (TCM) formulation, may short the course of the disease and reduce the occurrence of PID sequelae, but its pharmacological action and potential mechanism have not been fully elucidated. Here, we aimed to investigate the therapeutic effects and mechanism of KFXYS in rats with PID.

Materials and Methods: A PID rat model was constructed through endometrial mechanical injury and pathogen infection. The rectal temperature was measured during the 14-days course of treatment, and the white blood cell (WBC) count in the blood and the levels of cytokines (IFN-γ, IL-1β, IL-4, TNF-α) in the serum were evaluated by ELISA. Hematoxylin and eosin (HE) staining was performed to analyze pathological changes, and transmission electron microscopy (TEM) was used to observe ultrastructural changes. The p-p65/p65 protein expression was evaluated by western blotting and the levels of MMP-2 and TGF-β in adhesion tissues were assessed by immunohistochemistry.

Results: KFXYS lowered the rectal temperature and the WBC counts in the blood in the acute stage of PID and alleviated inflammatory cell infiltration of the uterus, especially when combined with levofloxacin. KFXYS significantly decreased the levels of proinflammatory cytokines (IFN-γ, IL-1β, IL-4) and adhesion-related factors (TNF-α) and protected the ultrastructure of endometrial epithelial cells. Mechanistically, KFXYS inhibited the NF-κB activation by decreasing phosphorylation of p65, thus the alleviation of inflammation further reduced the expression of TGF-β and MMP-2, and inhibited the occurrence of uterine adhesions.

Conclusion: These results revealed that KFXYS alleviated pelvic inflammation and effectively inhibits inflammation-associated adhesion, which indicated the potential role of KFXYS for treatment of PID and the prevention of PID sequelae.

Evidence for the Use of Complementary and Alternative Medicine for Pelvic Inflammatory Disease: A Literature Review

Pelvic inflammatory disease (PID), a common infectious disease of the female reproductive tract, is mainly characterized by abdominal/pelvic pain and tenderness of the uterus, cervix, or adnexa on physical exam. In recent years, its incidence has gradually increased yearly due to numerous factors, including sexually transmitted diseases and intrauterine operations. Based on self-report of PID in the National Health and Nutrition Examination Survey (NHANES) 2013-2014 survey, PID impacts approximately 2.5 million women in the US during their reproductive age. Although empiric treatments such as antibiotics or surgery could alleviate the related symptoms of PID, its unsatisfactory obstetric outcome and high relapse bring heavy physical and psychological burden to women. Complementary and alternative medicine (CAM), a complementary therapy other than Western medicine with a complete theoretical and practical system, has been attached to importance in the world due to its remarkable efficacy. More people are accepting and trying to use CAM to treat gynecological diseases, including infertility, polycystic ovary syndrome, and PID, but its efficacy and mechanism are still controversial. This article reviews the previous literature systematically focusing on the effectiveness, safety, and mechanism of CAM in the treatment of PID to provide an evidence-based basis for the clinical application of CAM in patients with PID.

Identifying the clinical presentations, progression, and sequela of pelvic inflammatory disease through physiological, histological and ultrastructural evaluation of a rat animal model

Background

Patients with pelvic inflammatory disease (PID) are at an increased risk of ectopic pregnancy, infertility, and varying degrees of chronic pelvic pain. The aims of this study were to establish a rat model of PID and characterize its progression in order to assist in the study of pathophysiological mechanisms and to provide animal model for future studies of PID treatments.

Methods

Fifty Sprague-Dawley rats (female, 6-weeks-old) were divided into a model group (n=28) and a control group (n=22). The rat endometrium was mechanically injured by a needle which moved back and forth 3 times on the endometrial tissue, and a mixed bacterial solution (6×10⁸ CFU) of equal concentrations of Escherichiacoli and Staphylococcus aureus was injected into both horns of the rat uterus. Physiological characteristics including weight, temperature, blood, and inflammatory factors were compared, and immunohistochemistry and transmission electron microscopy were used to evaluate the progress and sequela of PID.

Results

The model rats experienced acute PID in the first 14 days and exhibited higher body temperatures and decreased body weight. Infection-related factors in the blood were also significantly changed compared with the normal group, with obviously increased serum levels of C-reactive protein (CRP), interferon gamma (IFN-γ), and interleukin-4 (IL-4). Congestion and edema were observed in the uteri of the model rats, followed by infiltration of numerous inflammatory cells and ultrastructural morphology changes. Histological examination of the uterus showed that adhesion initially appeared at approximately 21 days. In addition to the increased collagen fibers biomass, the expression of transforming growth factor-beta 1 (TGF-β1) was elevated, which might have contributed to pelvic tissue adhesion formation in the PID sequela.

Conclusions

This study clearly described the characteristics and progression of PID in a rat model. The detailed evidence increased our understanding of the pathogenesis and progression of PID and may be useful for future studies of PID treatments.

How prevalent are symptoms and risk factors of pelvic inflammatory disease in a sexually conservative population

Background

Pelvic inflammatory disease (PID) is the inflammation of the adnexa of the uterus, that mainly manifests in a subclinical/chronic context and goes largely underreported. However, it poses a major threat to women’s health, as it is responsible for infertility and ectopic pregnancies, as well as chronic pelvic pain. Previous studies in Jordan have not reported PID, attributed mainly to the social structure of the country which largely represents a sexually conservative population. Our study aims to report the clinical symptoms that point towards PID and investigate the major risk determinants for the Jordanian population, in a cross-sectional study, using our scoring system based only on clinical data and examination.

Methods

One hundred sixty-eight consecutive adult women that came in the Outpatient Clinics of Gynaecological Department of the Jordan University Hospital were interviewed and their medical history and symptoms were registered and analysed. A Score for PID symptoms, we developed, was given to each woman. Results and correlations were then statistically tested.

Results

Our study population consisted of relatively young women (37.7 ± 11) that had their first child at an average age of 24.1 (± 4.8) and a mean parity of 3.1 (± 2.2). Fifty-eight women (34.5%) reported having undergone at least one CS, while the mean PID Symptom Score was 3.3 (± 2.3). The women in our study exhibited 8 symptoms of PID, namely dysmenorrhea and vaginal discharge; being the commonest (45.2% and 44.6% respectively), in addition to chronic pelvic pain, pelvic heaviness, menorrhagia, dyspareunia, urinary symptoms, and smelly urine. They also reported history of 3 conditions that can be attributed to PID, that is infertility, preterm labour, and miscarriages.

Conclusions

Our PID Scoring System seems to identify the risk factors of PID and predict well the PID likelihood. This score predicts that women with higher parity, who used contraceptives and underwent any invasive medical procedure are expected to score higher in the PID Symptom Score. Our data also suggest that PID should not be ruled out in the Jordanian population when symptoms are compatible to this diagnosis.

As a sexually conservative country, Jordan is thought to have a low prevalence of pelvic inflammatory disease. The prevalence of STD pathogens is very low, however many patients present symptoms of PID, so we randomly interviewed 168 healthy participants and investigated symptoms related to PID. Surprisingly the percentage of participants who had symptoms of PID was high, reaching up to 64% for some symptoms. We then created a PID symptom score; where every symptom gets one mark (1–11), and tested it for association against independent factors. As a result, it can be predicted that a woman with higher parity, who used contraceptives, and underwent E & C, D & C, HSG, or Hysteroscopy is expected to score higher in the PID Symptom Score.

This result draws the attention to PID incidence in similar conservative communities, and therefore further research is needed to confirm the prevalence of PID and identify the causative factors.

Vaginal microbiomes and ovarian cancer: a review

The human microbiome, often termed as "the forgotten organ", is an aggregation of microorganisms and their genomes that forms a mutualistic complex with the host. Recent research has shown the symbiotic merits of a microbiome ecosystem and its crucial role in the hosts' physiological functions. Disruption of this symbiotic relationship is prone to cause a broad spectrum of ailments, including cancer. The compositional and environmental factors that tip the scales from beneficial co-existence to the development of malignancy is actively investigated. Herein we review the latest research in knowledge regarding the association between the vaginal microbiomes and oncogenesis, with a particular focus on ovarian carcinoma.

[Pelvic Inflammatory Disease - Synergies between Family Practices and Gynaecological Specialised Assessment]

Pelvic Inflammatory Disease - Synergies between Family Practices and Gynaecological Specialised Assessment Abstract. The 'pelvic inflammatory disease' (PID) describes an ascending inflammation of the upper female genital tract, beginning with a local cervicitis and proceeding to endometritis and adnexitis. It is a common clinical picture with rising numbers in recent years, and it occurs both in gynaecological and general practice. The symptoms are often unspecific, discrete or althogehter lacking. In order to reduce long-term risks of chronic pelvic pain, sterility and/or ectopic pregnancies, rapid diagnosis followed by immediate therapy and a good interdisciplinary cooperation are necessary. Screening programs for chlamydia and gonococcus as the most common pathogens of PID have not yet been implemented in Switzerland so far.

Comparison of the Analgesic and Anti-Inflammatory Effects of Xiaoyuningkun Decoction with Cynanchum Paniculatum and Fukeqianjin in a Mouse Model of Pelvic Inflammatory Disease

BACKGROUND Preclinical and clinical studies have shown that the extract of Cynanchum paniculatum (bunge) kitag and the fukeqianjin formulation have beneficial effects in pelvic inflammatory disease (PID). This study aimed to compare the effects of Cynanchum paniculatum and fukeqianjin with a new decoction, xiaoyuningkun, consisting of Melia toosendan, Angelica biserrata, and Cynanchum paniculatum, in a mouse model of PID. MATERIAL AND METHODS The mouse model of PID included injection of the upper genital tract with hydrochloric acid (HCl) and lipopolysaccharide (LPS). The control group underwent sham treatment with 0.9% physiological saline. Cynanchum paniculatum, fukeqianjin, and xiaoyuningkun decoction were administered orally for 15 days. Acetic acid-induced writhing and thermal nociception hot plate tests evaluated the analgesic effects of treatment. Mouse uterus and Fallopian tubes were examined histologically to evaluate the degree of inflammation. Immunohistochemistry was used to measure the protein expression of intercellular adhesion molecule-1 (ICAM-1) and vascular endothelial growth factor (VEGF). Enzyme-linked immunosorbent assay (ELISA) measured serum levels of inflammatory cytokines. RESULTS Treatment with xiaoyuningkun decoction significantly reduced the pain threshold in the mouse model of PID and the degree of inflammation in the uterus and Fallopian tubes compared with Cynanchum paniculatum and fukeqianjin. Cynanchum paniculatum decoction significantly reduced the serum levels of interleukin-1ß (IL-1ß), tumor necrosis factor-alpha (TNF-alpha), ICAM-1, and VEGF, and the expression of ICAM-1 and VEGF in the mouse uterus and Fallopian tubes. CONCLUSIONS The new xiaoyuningkun decoction had analgesic and anti-inflammatory effects in the mouse model of PID, possibly by inhibiting ICAM-1, VEGF, and inflammatory cytokines.

Salpingitis Impairs Bovine Tubal Function and Sperm-Oviduct Interaction

Salpingitis is a common cause for subfertility and infertility both in humans and animals. However, the effects of salpingitis on tubal function and reproductive success are largely unknown. Therefore we set out to investigate the effects of inflammation on sperm and oocyte transport and gameto-maternal interaction in the oviduct using the bovine as a model. For this purpose, oviducts revealing mild (n = 45), moderate (n = 55) and severe (n = 45) inflammation were obtained from cows immediately after slaughter and investigated by live cell imaging, histochemistry and scanning electron microscopy. Our studies showed that endometritis was always correlated with salpingitis. Moderate and severe inflammation caused a significant increase in the thickness of tubal folds (p < 0.05). Severe inflammation was characterized by luminal accumulations of mucus and glycoproteins, increased apoptosis, loss of tight junctions and shedding of tubal epithelial cells. The mean ciliary beat frequency (CBF) in the ampulla was significantly reduced as compared to the controls (p < 0.05). The higher the grade of inflammation, the lower was the CBF (p < 0.001). In severe inflammation, spermatozoa were stuck in mucus resulting in decreased sperm motility. Our results imply that tubal inflammation impairs proper tubal function and leads to reduced sperm fertilizing capacity.

The Anti-Inflammatory Effect of Feiyangchangweiyan Capsule and Its Main Components on Pelvic Inflammatory Disease in Rats via the Regulation of the NF-κB and BAX/BCL-2 Pathway

Although gastroenteritis and pelvic inflammatory disease (PID) occur in the gastrointestinal tract and pelvis, respectively, they display similar pathogeneses. The incidence of inflammation in these conditions is usually associated with dysbacteriosis, and, at times, they are caused by the same pathogenic bacteria, Escherichia coli and Streptococcus aureus. Feiyangchangweiyan capsule (FYC) is a traditional Chinese patent medicine that is widely used to treat bacterial dysentery and acute and chronic gastroenteritis. However, whether it has an effect on PID is unclear. The aim of this study was to investigate the anti-inflammatory effect of FYC and its main components, gallic acid (GA), ellagic acid (EA), and syringin (SY), on a pathogen-induced PID model and illustrate their potential mechanism of action. Female specific pathogen-free SD rats (n = 1110) were randomly divided into control, PID, FYC, GA, EA, SY, GA + EA, GA + SY, EA + SY, GA + EA + SY, and Fuke Qianjin capsule (FKC) positive groups. Histological examination and enzyme-linked immunosorbent assay (ELISA) were carried out as well as western blot analysis to detect the expression of NF-κB, BAX, BCL-2, and JNK. In this study, FYC and its main components dramatically suppressed the infiltration of inflammatory cells, reduced the production of IL-1β, TNF-α, and MCP-1, and elevated the IL-10 level to varying degrees. We also found that FYC and its main components inhibited the expression of BAX induced by infection and increased the expression of Bcl-2. FYC, GA, EA, and SY could also block the activation of the NF-κB pathway. Finally, we found that the phosphorylation of JNK could be decreased by FYC, GA, and SY. FYC and its main components exhibit anti-inflammatory effect on a pathogen-induced PID model by regulating the NF-κB and apoptosis signaling pathways.

Uncommon cause of pelvic inflammatory disease leading to toxic shock syndrome

A 44-year-old Caucasian female with a history of endometriosis is admitted to the intensive care unit due to severe left lower quadrant abdominal pain, nausea and vomiting. With patients' positive chandelier sign on pelvic examination, leucocytosis, elevated erythrocyte sedimentation rate and elevated C-reactive protein indicated that she had pelvic inflammatory disease (PID). PCR tests were negative for Neisseria gonorrhoeae and Chlamydia trachomatis; however, her blood and urine cultures grew Group A streptococci (GAS) with a negative rapid Streptococcus throat swab and no known exposure to Streptococcus On further review, patient met criteria for GAS toxic shock syndrome based on diagnostic guidelines. The patient was promptly treated with intravenous antibiotics and supportive care, and she acutely recovered. This case demonstrates a rare cause of PID and an atypical aetiology of severe sepsis. It illuminates the importance of considering PID as a source of infection for undifferentiated bacteraemia.