A 23-year-old woman comes to the office with worsening fever, chills, and lower abdominal pain for 3 days. The patient has been taking nonsteroidal anti-inflammatories for pain relief. She also has increasing malodorous vaginal discharge. The patient has a history of 2 episodes of pelvic inflammatory disease that required hospitalization and intravenous antibiotic treatment. She has smoked a pack of cigarettes daily for 7 years and consumes 1 or 2 beers daily. The patient has had 6 sexual partners over the last 6 months. She had an intrauterine device (IUD) placed a year ago and inconsistently uses barrier contraception. The patient has no known drug allergies. Temperature is 38.3 C (100.9 F), blood pressure is 110/70 mm Hg, pulse is 100/min, and respirations are 20/min. Weight is 60 kg (132.3 lb) and height is 157.5 cm (5 ft 2 in). Examination shows a soft, nondistended abdomen with mild rigidity and rebound tenderness in the lower abdomen; bowel sounds are present. There is no hepatosplenomegaly. No lesions are present on the vulva or vagina. Pelvic examination reveals cervical motion and bilateral adnexal tenderness as well as purulent discharge from the cervical os. The IUD strings are visible at the external cervical os. Laboratory results are as follows:
| Hemoglobin | 12.4 g/dL |
| Platelets | 200,000/mm3 |
| Leukocytes | 14,000/mm3 |
Urinalysis shows 50+/hpf of WBCs. Urine pregnancy test is negative. Nucleic acid amplification testing is positive for Neisseria gonorrhoeae. Pelvic ultrasound reveals a dilated fallopian tube filled with debris. Which of the following is the strongest risk factor for this patient's condition?
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This patient's fever, abdominal pain, purulent cervical discharge, and cervical motion tenderness are the classic presentation of pelvic inflammatory disease (PID). Gonococcal cervicitis predisposes the upper reproductive tract (eg, uterus, fallopian tube) to the polymicrobial infection of PID. Acute complications of PID include tubo-ovarian abscess, pyosalpinx, and perihepatitis (eg, Fitz-Hugh-Curtis syndrome). Long-term complications include infertility and increased risk of ectopic pregnancy due to fallopian tube damage.
Risk factors for PID include multiple sexual partners, age 15-25, previous episodes of PID, inconsistent use of barrier contraception, and a partner with a sexually transmitted infection. Studies show that among all PID risk factors, having multiple sexual partners is associated with the highest increase (4.6- to 20-fold) in risk for PID occurrence.
(Choice A) Being age 15-25 is a risk factor for PID due to the frequency of Chlamydia trachomatis and Neisseria gonorrhoeae infection in this age group. However, being age 15-25 is associated with less risk than a history of having multiple sexual partners.
(Choice B) Use of barrier contraception, particularly condoms, helps prevent PID. Inconsistent use of condoms approximately doubles the risk of PID; having multiple sexual partners increases the risk by 4.6- to 20-fold. Therefore, a woman not using condoms with a single sexual partner is less likely to have PID than a woman using condoms with multiple sexual partners.
(Choice C) There is minimal increase in the risk of PID with the use of an intrauterine device (IUD); this risk is typically limited to the first few weeks after insertion.
(Choice E) Women with previous episodes of PID have a 2.3-fold increase in the risk for recurrent infection.
Educational objective:
Having multiple sexual partners is associated with the highest increase in risk for pelvic inflammatory disease (PID). Other risk factors include being age 15-25, previously having PID, inconsistently using barrier contraception, and having a partner with a sexually transmitted infection.