Can the use of intra-vaginal (intrauterine device) pessaries with microbiome probiotics cause Pelvic Inflammatory Disease (PID)?

Intravaginal Probiotic Pessaries and Risk of Pelvic Inflammatory Disease

There is no documented evidence that intravaginal probiotic pessaries cause pelvic inflammatory disease (PID). Based on the available evidence, probiotic pessaries used for vaginal microbiome support do not increase the risk of PID when used appropriately.

Etiology and Pathogenesis of PID

• PID is primarily caused by ascending infection from the endocervix to the endometrium and fallopian tubes, most commonly associated with sexually transmitted infections (STIs) like Neisseria gonorrhoeae and Chlamydia trachomatis, as well as various anaerobic and aerobic bacteria 1.
• The pathogenesis typically involves direct canalicular spread of organisms from the lower genital tract to the upper genital tract 1.
• Multiple organisms are usually implicated in PID cases, with C. trachomatis recovered from the cervix in 5-39% of women with PID and N. gonorrhoeae isolated from the cervix in 27-80% of cases 1.

Risk Factors for PID

• The primary risk factors for PID include:

  • Current or recent STIs, particularly gonorrhea and chlamydia 1
  • Multiple sexual partners 2
  • History of PID 1
  • Younger age 1
  • Uterine instrumentation, particularly IUD insertion (risk highest in first 20 days after insertion) 3, 4

• While intrauterine devices (IUDs) have historically been associated with increased PID risk, recent evidence shows this risk is primarily limited to the insertion period (first 20 days) and in women with pre-existing STIs 3, 2.

Probiotics and Vaginal Health

• A 2024 randomized controlled trial specifically studying vaginal probiotic suppositories in pessary users found no adverse effects related to PID, with only minor, self-limiting side effects reported in 39.1% of users 5.
• This study demonstrated that vaginal probiotic suppositories did not negatively affect the vaginal microenvironment after 3 months of use 5.

Diagnosis of PID

• The Centers for Disease Control and Prevention recommends diagnosing PID based on minimum criteria including:

  • Uterine/adnexal tenderness
  • Cervical motion tenderness 1

• Additional supportive criteria include:

  • Oral temperature >101°F (>38.3°C)
  • Abnormal cervical or vaginal discharge
  • Elevated inflammatory markers (ESR, CRP)
  • Laboratory confirmation of cervical infection with N. gonorrhoeae or C. trachomatis 1

Management Considerations

• If PID is suspected, prompt antibiotic treatment is essential as delay can lead to long-term sequelae 1.
• Recommended treatment regimens include:
  • Parenteral therapy with cefotetan or cefoxitin plus doxycycline, or
  • Clindamycin plus gentamicin 1, 6
• Treatment should provide coverage against N. gonorrhoeae, C. trachomatis, anaerobes, gram-negative facultative bacteria, and streptococci 1.

Key Points for Clinical Practice

• There is no evidence in the literature linking probiotic vaginal pessaries to PID development 5.
• When evaluating a patient with suspected PID, focus on common risk factors such as STIs, recent instrumentation, or history of PID rather than probiotic use 1.
• If a patient develops PID symptoms while using probiotic pessaries, standard PID evaluation and treatment should be initiated, but the probiotics themselves are unlikely to be the causative factor 6.

Common Pitfalls to Avoid

• Misattributing PID symptoms to probiotic use without screening for common causes like STIs 1.
• Failing to recognize that PID is typically polymicrobial and requires broad-spectrum antibiotic coverage 1.
• Delaying treatment when PID is suspected, as prompt antibiotics are crucial for preventing long-term sequelae 1.