HPV Does Not Cause Pelvic Inflammatory Disease
HPV is not a causative agent of PID; it is merely found as a concomitant infection in some women with PID, particularly those who are HIV-positive. The established causative organisms of PID are Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and bacterial vaginosis-associated anaerobes 1, 2, 3, 4.
The Evidence on HPV and PID
HPV as a Co-infection, Not a Cause
The CDC guidelines explicitly clarify that in HIV-infected women with PID, microbiologic findings show higher rates of concomitant HPV infections and HPV-related cytologic abnormalities, but this represents co-infection rather than causation 5. The key distinction is:
- HPV was found at higher rates in HIV-positive women with PID compared to HIV-negative women with PID 5
- This association reflects shared risk factors (sexual transmission) rather than HPV causing the upper genital tract infection
- The actual causative organisms remained the same regardless of HPV presence 5
True Causative Organisms of PID
All PID treatment regimens must cover the established causative pathogens: N. gonorrhoeae, C. trachomatis, anaerobes, gram-negative facultative bacteria, and streptococci 1, 2, 4. This microbiologic requirement for treatment underscores that these—not HPV—are the organisms responsible for the infection.
The polymicrobial nature of PID includes 3, 4, 6:
- Chlamydia trachomatis and Neisseria gonorrhoeae (most common sexually transmitted causes)
- Bacterial vaginosis-associated organisms (predominantly anaerobes)
- Mycoplasma genitalium
- Enteric gram-negative bacteria
- Respiratory pathogens in rare cases
Clinical Implications
Why This Distinction Matters
Understanding that HPV does not cause PID is critical because:
- Treatment decisions: PID requires broad-spectrum antibiotics targeting bacteria, not antiviral therapy 1, 2
- Prevention strategies: PID prevention focuses on screening for C. trachomatis and N. gonorrhoeae, not HPV vaccination 3
- Partner management: Sex partners require empiric treatment for gonorrhea and chlamydia, regardless of HPV status 1, 2
The HPV-Cervical Cancer Connection
While HPV does not cause PID, one study suggested that women with PID may have higher HPV prevalence (33.74% vs 26.40%), potentially indicating increased cervical cancer risk 7. However, this reflects:
- Shared sexual transmission routes
- Common risk factors (multiple partners, young age, lack of barrier contraception)
- Not a causal relationship between PID and HPV acquisition
Common Pitfall to Avoid
Do not delay or modify PID treatment based on HPV status. The presence or absence of HPV infection should not influence:
- The decision to treat for PID 2
- The choice of antibiotic regimen 1, 2
- The urgency of initiating therapy 2
The CDC maintains a low threshold for empiric PID treatment in any sexually active woman with uterine/adnexal tenderness or cervical motion tenderness, without waiting for any confirmatory testing including HPV 2.