Infectious Diseases in Obstetrics and Gynecology 7:248-252 (1999) (C) 1999 Wiley-Liss, Inc. Pelvic Inflammatory Disease in the Postmenopausal Woman S.L. Jackson* and D.E. Soper Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC ABSTRACT Objective: Review available literature on pelvic inflammatory disease in postmenopausal women. Design: MEDLINE literature review from 1966 to 1999. Results: Pelvic inflammatory disease is uncommon in postmenopausal women. It is polymicro- bial, often is concurrent with tuboovarian abscess formation, and is often associated with other diagnoses. Conclusion: Postmenopausal women with pelvic inflammatory disease are best treated with in- patient parenteral antimicrobials and appropriate imaging studies. Failure to respond to antibiotics should yield a low threshold for surgery, and consideration of alternative diagnoses should be entertained. Infect. Dis. Obstet. Gynecol. 7:248-252, 1999. (C) 1999Wiley-Liss, Inc. KEY WORDS menopause; tuboovarian abscess; diverticulitis elvic inflammatory disease (PID) is a common stance abuse, lack of barrier contraception, use of and serious complication of sexually transmit- an intrauterine device (IUD), and vaginal douch- ted diseases in young women but is rarely diag- ing. z The pathophysiology involves the ascending nosed in the postmenopausal woman. The epide- spread of pathogens initially found within the en- miology of PlD,.as well as the changes that occur in docervix, with the most common etiologic agents the genital tract of postmenopausal women, ex- being the sexually transmitted microorganisms plain this discrepancy. The exact incidence of PID Neisseria gonorrhoeae and Chlamydia trachomatis. in postmenopausal women is unknown; however, These bacteria are identified in 60-75% of pre- in one series, fewer than 2% of women with tubo- menopausal women with PID. 3 Other responsible ovarian abscess formation were postmenopausal. microorganisms include respiratory pathogens, Despite the rarity with which PID occurs in the such as Haemophilus influenzae4,s and Streptococcus postmenopausal woman, consideration and early pyogenes, s and bacterial vaginosis-associated micro- recognition of the diagnosis along with appropriate organisms (Prevotella, Peptostreptococcus). 3,6 therapy can decrease the morbidity and mortality Cervical factors play a role in the development associated with what is usually a serious infection. of PID. The columnar epithelium of the endocer- vix is found everted in women of PATHOPHYSIOLOGY commonly repro- ductive age, and this is accentuated with use of oral Pelvic inflammatory disease is an infection of the contraceptive pills. Both N. gonorrhoeae and C. tra- upper genital tract most commonly seen in young chomatis attach preferentially to these columnar en- women. Typically, the risk factors associated with docervical cells. With menopause, the cervical PID are young age, low socioeconomic status, sub- transformation zone is anatomically located within *Correspondence to: Susan L. Jackson, MD, Department of Obstetrics and Gynecology, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 634, PO Box 250619, Charleston, SC 29425. E-mail: [email protected] Received March 1999 Review Article Accepted 17 June 1999 PELVIC INFLAMMATORY DISEASE IN POSTMENOPA USAL WOMEN JACKSON AND SOPER the endocervical canal and is smaller than in pre- menopausal PID had previous uterine instrumen- menopausal women, decreasing the area of attach- tation, the majority within 2 weeks of the diagno- ment available to C. trachomatis and N. gonorrhoeae. sis. 13 Both a fractionated dilation and curettage ta These changes most likely lower the susceptibility and office sampling with an aspirating pipette can of the postmenopausal woman to infection. The be associated with the development of PID. Ag- endocervix also acts as a functional barrier to as- gressive sampling may lead to uterine perforation, cending infection. This barrier can be attenuated which allows the direct inoculation of microorgan- by the changing rheologic properties of the cervical isms into the peritoneal cavity. mucus as noted during ovulation or breached by Structural abnormalities of the genital tract, such the occurrence of retrograde menstruation. Physi- as cervical stenosis, uterine anatomic abnormalities, ologically, the cervical mucus of the menopausal and tubal disease, are also associated with an in- woman is more tenacious and serves as a mechani- creased risk of developing PID.6 A history of cer- cal barrier to ascending infections. Lack of men- vical conization, cryotherapy, or loop electrosurgi- struation in menopausal women decreases the risk cal excision procedure can be associated with the of infection of the upper genital tract. development of cervical stenosis. This, in addition The direct extension of infectious processes to other lesions, such as visible cervical malignan- from adjacent intraabdominal viscera is more likely cies, submucous myomas, and endometrial polyps, to be associated with PID in older women. Disor- can block the efflux of blood or other fluids from ders such as diverticulitis, Crohn disease, colonic the uterine cavity. A collection of fluid within the cancers, and appendicitis have been associated uterine cavity, such as blood (hematometra) or with a direct spread of infection to the ovaries, ovi- clear fluid (hydrometra), can become contaminated ducts, and uterus and manifest as a unilateral or with microorganisms, causing a pyometra. This in- bilateral tuboovarian abscess. 1,7,8 Fistula formation fected fluid may then reflux into the fallopian from an abscess cavity to the genital tract has also tubes and subsequently into the peritoneal cavity. been described.9,1 A prior history of PID with subsequent tubal scarring or hydrosalpinx formation results in fallo- RISK FACTORS pian tubes that are more susceptible to nonsexually Older women are less likely to have risk factors transmitted aerobic pathogens, such as H. influen- known to be associated with exposure to sexually zae, group B streptococcus, and Escherichia coli. 5 transmitted microorganisms. Behavioral, physi- Chronic or recurring PID, however, appears to be ologic, and anatomic alterations that occur with ad- an uncommon cause of pelvic organ infection in the vancing age offer barriers to the usual means of older population. 14 developing PID. The vaginal flora of postmenopausal women is Sexual activity is a prerequisite for the develop- more likely to be populated with aerobic gram- ment of PID in younger women, and high coital negative bacteria, especially E. coli, particularly if frequency has been associated with acquiring the they do not take estrogen replacement therapy. 5 If disease. The precise mechanism determining the these potentially pathogenic bacteria gain entry spread of microorganisms from the lower genital into the upper genital tract and a concomitant ab- tract to the upper genital tract is poorly understood; normality fails to allow the secretions of the upper however, this suggests a role of spermatozoa as a genital tract to be drained, an environment condu- vehicle for transporting the microorganisms to the cive to suppurative infection can occur. Degenera- upper genital tract. Most older women have fewer tion of uterine myomas has been associated with sexual partners and less frequent coital activity, lz bacterial superinfection and infection of the genital making them less likely to develop PID. tract. 6 A risk factor associated with the development of Finally, a "forgotten" IUD may be associated PID in the postmenopausal woman is uterine in- with a more serious genital tract infection. Landers strumentation. Such procedures may introduce mi- et al. revealed that up to one third of women with croorganisms into the endometrial cavity, which tuboovarian abscess currently or were past users of can lead to an infection of the upper genital tract. IUDs. 6 In some cases, infections may be due to One series reported that 45% of women with post- Actinomyces israelii, a gram-positive anaerobic organ- INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 249 PELVIC INFLAMMATORY DISEASE IN POSTMENOPA USAL WOMEN JACKSON AND SOPER ism. This infection occurs almost exclusively in Additional laboratory values that may aid in the women who have an IUD in situ. 17 Characteristi- diagnosis include a complete blood count (specifi- cally, these patients have pelvic abscess formation cally to identify a leukocytosis) and C-reactive pro- and may exhibit evidence of fistula development. tein. A Papanicolaou smear of the ecto- and endo- On pelvic exam, palpable indurated masses may be cervix should be obtained if not recently per- present, suggesting a possible genital tract malig- formed. Endometrial biopsy should be considered nancy. and, if obtained, sent for pathologic and microbio- logic evaluation. Computed tomography (CT) or MICROBIOLOGY pelvic ultrasonography should be performed in The postmenopausal woman diagnosed with PID most postmenopausal women with PID, because is less likely to harbor a sexually transmitted organ- the majority will have evidence of a tuboovarian ism than the premenopausal woman. In most re- abscess. 1,7,as-z0 ported cases, 1,7,18,19 the organisms most frequently In premenopausal patients, pelvic organ tender- encountered were E. coli (76%) and Klebsiella ness and either leukorrhea or mucopurulent endo- (43%). These microorganisms were also identified cervicitis must be present to make the clinical di-