Chapter 5: Beyond Conception

Beyond Conception:
Other Effective Applications of Antibiotic Therapy

For most people the pelvic area is a dark mysterious netherworld. Messy, awkward, and troublesome processes take place there that upset our equilibrium and that our upbringing trains us to ignore. The nervous system may register all sorts of ambiguous sensations from the pelvic area -- queasiness, strain, pressure, itchiness, soreness, burning, or cramping -- but the brain usually shuns thinking about them.

Often, however, a signal from the pelvic area becomes so strong it's incapacitating. In a man's case, the most common symptom of this type is an excruciating pain whenever he urinates, possibly accompanied by a strange discharge from the penis. In a woman's case, a variety of intense symptoms are possible, befitting the greater extent and complexity of her genital tract. A chronic irritation in her vagina may make it impossible for her to enjoy sexual intercourse. A swollen and tender abdomen may destroy her ability to concentrate on her work.

By the time a pelvic signal is this pronounced, the problem behind the signal may be far advanced. In addition to jeopardizing the victim's ability to parent a child, it may even threaten his or her life. Tragically, many equally critical problems never do announce themselves. Instead they continue to worsen, not only from their lack of detection but also from our partly unintentional, partly willful ignorance and neglect of what can happen "down there."

In my practice, I use antibiotic therapy to treat many bacteria-related reproductive health problems besides infertility, from relatively simple ones like vaginitis and prostatitis to complex ones like PMS and PID. Although each of these conditions can be a precursor to full-blown infertility, they are all illnesses in their own right. Many of the people who come to my laboratory to be treated for these illnesses-or to be treated so that these illnesses won't develop-are not interested in having children, at least not right away. Instead, they're concerned about their own well-being. In this chapter, I'll discuss the major reproductive problems short of infertility and how my therapy works to restore health.

CHLAMYDIA: FIGHTING THE PHANTOM

Today, the fastest-growing and most prevalent sexually transmitted disease (STD) is chlamydia infection. In the United States alone, there are over 4.5 million newly reported cases of chlamydia infection each year, compared to one million cases of gonorrhea (the second highest STD). Among the population at large, one out of every ten people is suspected of harboring this troublesome bacterium in his or her genital tract.

Perhaps chlamydia infection has always been the most prevalent STD. If so, the chlamydia bacterium has certainly done its damage in the dark. Prior to the late 1970s, it was familiar to medical science only as the cause of conjunctivitis (or eye inflammation). Doctors were aware that a newborn could develop conjunctivitis after having been exposed to chlamydia in the mother's genital tract, but they did not associate it with infection of the genital tract itself, nor did they consider that it might be transmitted sexually.

Now, thanks to the invention of more sensitive testing procedures, we know chlamydia is the reigning monarch among STDs. I also believe, as I stated in Chapter 3. that chlamydia infections in the genital tract can result from vertical transmission.

Whichever way the chlamydia is transmitted to its victim, the results can be disastrous. Not only is its potential for devastation so vast, but it also operates so insidiously. Gonorrheal and syphilitic infections produce gross symptoms fairly quickly; only about 10 percent of the time are these infections asymptomatic for long periods of time. Chlamydia infections, by contrast, are asymptomatic throughout in an estimated 65 percent of all cases.

In men, chlamydia can move through the genital tract like a stealth bomber, progressively causing irritation and swelling of the urethra (urethritis), the prostate (prostatitis) the epididymis (epididymitis), and finally, the testes (orchitis). When symptoms do appear, they include "burning" during urination, itching, watery discharge, and more rarely, a scrotum that is visibly (if not painfully) swollen. A case of chlamydia infection so far advanced that it affects the immune system in general may produce secondary symptoms, such as joint pain (arthritis) and painful swelling of the eye (conjunctivitis).

The appropriate treatment for a chlamydia infection is a comprehensive, high-dosage antibiotic program as soon as possible. If the infection isn't wiped out early in its history, it's very difficult later to get rid of it entirely. Consider the case of Derek, who sought my advice in 1988 for an infection that had been plaguing him since 1985.

Derek owns an international company and frequently spends long periods of time abroad on business. He told me he first noticed a transparent, slightly viscous discharge from his urethra shortly after a visit to one of Bangkok's infamous massage parlors. A urologist in Thailand diagnosed the problem as a chlamydia infection. Whether or not Derek picked up that infection during his massage is a moot point. He was lucky to have a symptomatic alert and a rationale for seeking help. He was unlucky, however, in his initial therapy. After the recommended course of treatment, he was fine for a few days, but as soon as he returned to the United States, the symptoms flared up again.

Derek went to a new urologist, who, like his Thai counterpart, told him he had a chlamydia infection and prescribed the "standard" ten-day course of oral tetracycline. When that didn't work, the very same program was stubbornly repeated. Again, his symptoms returned within a few days, even more virulent than they had been before. By now, urinating was always acutely painful for Derek, and the discharge was about twice as copious. "I was so frustrated," he admitted, "that I was sure that the problem was something else, something more serious than what the two doctors had told me."

Determined as he was, Derek went to a third urologist and demanded that he do everything possible to get to the bottom of his problem. The urologist advised a cystoscopy. Hearing this from Derek, I was quite bothered. Whatever pressure Derek may have been exerting as a patient, the urologist had extremely little justification for suggesting this relatively invasive procedure. A cystoscopy is a surgically facilitated exploration of the genital tract designed to establish the possible presence of cancer or a polyp. In a young man (Derek was then twenty-five years old), the symptoms he presented almost always point to bacterial infection, and every possible means of investigating such an infection should have been tried first.

Understandably, the cystoscopy did not reveal anything suspicious. The urologist stopped there-once more, failing to pursue other, more appropriate forms of testing. He put Derek on four months of sulfa drugs, a somewhat blind approach, to Derek's problem, and the two of them hoped for the best. They hoped in vain. Derek's symptoms came and went from month to month. On the average, nothing changed.

Finally, Derek's girlfriend brought him to me. A meticulously thorough analysis of his semen showed the chlamydia was still present, aided and abetted by two anaerobes. This time around, I prescribed intravenous antibiotic treatment, involving a high dosage of doxycycline. Within two weeks, he was no longer experiencing painful urination or watery discharge. He has remained asymptomatic ever since. More important, his cultures show he has also stayed bacteria-free.

The prostate is a notoriously stubborn organ in the male genital area. Due to its complex anatomical structure and relatively compromised blood flow, bacteria harbored within its intricate globules are not easy to reach with medication. Therefore, an infection with chlamydia and/or a number of other bacteria can be very difficult to eradicate. Chronic prostatitis and, later on, chronic enlargement of the prostate, will lead to urinary-flow obstruction, which necessitates a prostatectomy (surgical removal of the prostate gland), either through the urethra or through the abdomen. Like Derek, many of my male patients who go through the intravenous antibiotic regimen are not worried about infertility. Instead, they are troubled by an ever-recurring prostate inflammation that blocks urination or renders it extremely painful.

In women, chlamydia can be responsible for similarly intractable infections. Moving up through the genital tract, it can cause irritation and swelling of the vagina (vaginitis), the cervix (cervicitis), the uterine lining (endometritis), the fallopian tubes (salpingitis), and the ovary (oophoritis).

As for symptoms of chlamydia infection, they're even scarcer among women than they are among men. Over 70 percent of female victims are asymptomatic. When symptoms do appear, they are usually very subtle and easily dismissed-ranging from an itching or burning sensation in the vagina to dull aches or "tender feelings" anywhere in the pelvic area. Nevertheless, these symptoms can be persistently discomforting, and in extreme cases, they can even be debilitating.

Physical pains and problems (including infertility) are not the only possible consequences of long-term chlamydia infection in the female genital tract. Such an infection can also play havoc with a woman's emotional and psychological health, particularly in the context of her sexual relationships. The story of one of my recent patients, Michelle, offers an instructive example.

Michelle developed an unusually troublesome case of vaginitis over the first few months of her marriage to Victor. By the fifth month, they were compelled to discontinue sexual intercourse. She was desperate enough and wealthy enough to consult seven gynecological specialists over the next three years. None of them was able to provide lasting relief.

Meanwhile, she and Victor were constantly teetering on the verge of divorce. They went through three rounds of marriage counseling during this time. Her continual lament was "I never had problems before I slept with him." His perpetual response was, "I don't have anything wrong; she needs help, not me."

When I first met Michelle, she frankly admitted she was an "emotional wreck," fearful of intimacy with her husband and, as she put it, "slightly paranoid -about therapists." By this time, Victor had finally agreed to cooperate in any testing and treatment program that showed promise. Fortunately, he was impressed with what I told him about the possible benefits of antibiotic therapy.

After reviewing their separate and combined histories, I was inclined to agree that Victor was the unwitting originator of Michelle's infection. Years before their marriage, he contracted gonorrhea. He discovered it right away, and it was quickly eradicated with penicillin-a commonplace scenario. Regrettably, the penicillin had no effect on the chlamydia bacterium that was also in his reproductive system.

For some time after an individual undergoes one kind of genital-tract infection, he or she is much less resistant to other kinds of infection. And that's what happened to Victor. Inside his genital tract, gonorrhea paved the way for a rapid spread of chlamydia, which, in addition to working on its own, is a highly opportunistic organism. He never felt the effects himself. Against the odds, his wife did.

It took two courses of antibiotic treatment administered by my laboratory before Victor and Michelle could reestablish a regular pattern of sexual intercourse. Even then, Michelle's "burning" symptom didn't abate until Victor began consistently using a condom.

Summarizing this case, I must conclude the following: although the antibiotic therapy wiped out the chlamydia infection entirely, it did not get rid of all irritating agents in Victor's seminal fluid. I must also conclude that one factor strongly mitigating against a complete cure was the tremendous psychological damage Michelle endured during her four-year battle with this notoriously insidious bacteria.

It's easy to cast Victor as a villain in the situation I've just recounted, but in handling case after case where a man has unknowingly contaminated his partner, I've learned to my sorrow that Victor's behavior - counterproductive as it may be - is normal. Anyone may experience difficulty admitting he or she is a "silent" carrier of disease. Faced with taking the blame for another person's pain, most people instinctively react with disbelief, defensiveness, and denial. To make matters worse, there's the widespread lack of knowledge about genital-tract function, dysfunction, and therapy that I mentioned at the beginning of this chapter. More than any other factor, this ignorance serves to perpetuate negative attitudes about sexually related issues and, therefore, negative reproductive health situations.

To underscore these points, let me describe the history of another bacterially infected woman, Pat, whose sensitive and intelligent partner, Gary, the apparent source of contamination, turned out to be maddeningly uncooperative. In this case, the harmful organism in Pat's genital tract was not chlamydia but an anaerobe. The presenting symptom, however, was the same: a burning itch signaling vaginitis. And what happened to Pat, medically and personally, could have happened no matter what specific bacterium was involved.

Trouble started for Pat and Gary four years before they came to me, during their sophomore year in college. Prior to the onset of their sexual relationship, both had been virgins. Pat first experienced vaginal irritation within their first month of intimacy. Five months later, her vaginitis was so far advanced that she and Gary had to discontinue having intercourse.

Gary was compassionate but, naturally, frustrated. His attitude worsened when a specialist told Pat, "You're allergic to your boyfriend"-a rather crude diagnosis! The specialist gave her antihistamines, but her vaginitis continued without relief. Next, the same specialist prescribed steroids to suppress her immune system so that it wouldn't generate such painful symptoms. This therapy also failed to work.

Gary's patience and faith were steadily eroding, and he was less and less afraid of expressing his negative feelings about the "sexual problem" he and Pat were experiencing and about therapists in general. Pat, on the other hand, felt obligated to suppress her fear and guilt and to persevere as optimistically as possible in her search for a cure.

Pat's next specialist performed a colposcopy (an examination of the vagina and cervix under a low-power microscope) and saw what he described as "mild inflammation." He attributed it to a virus and sent a biopsy to four other experts for their opinion. Two of them said her trouble probably was due to a viral infection; two of them said it probably wasn't. The upshot was that Pat visited yet another specialist. This one prescribed a high dosage of Prednisone, which caused her to develop a mild psychosis.

I was Pat's fourth specialist. Gary came to my laboratory with Pat in the spirit of a vigilant skeptic rather than an open-minded collaborator (he had recently become a medical student, which only made matters worse). By now, they had been together four years. Because they swore they had been faithful to each other all that time, I conjectured that either Pat or Gary (or both) had been infected by vertically transmitted bacteria. When Gary heard that he might be at fault and, regardless, that he, too, would have to be treated, he exploded. "That's totally asinine!" he said, venting years of anger. "I can't be infected-I don't have a single, solitary symptom!"

Reluctantly, I agreed to treat Pat alone, trusting their guarantee that she and Gary would avoid unprotected intercourse. Large quantities of a suspicious anaerobe showed up in her culture, so I put her on two weeks of intravenous clindamycin and gentamicin. Her symptoms disappeared for almost three weeks but then gradually reasserted themselves.

Gary, a self-proclaimed authority on medical matters, insisted that the early success of the antibiotic therapy had been due to a placebo effect; Pat had been so primed psychologically to feel better that she actually did, for a while. It wasn't my place to tell Gary he was wrong or to suggest his misguided concern might be making Pat's life all the more difficult. Accordingly, with great forbearance, I explained to him that Pat's infection had been so severe that her recovery was no doubt assuming a sinusoidal curve. In lay language, she would suffer gradually diminishing waves of recurring symptoms. Each bout with the "burning itch" I predicted, would be a little later and a little less intense until the condition ceased entirely.

All three of us followed the next twelve months very closely. Pat's first two bouts of vaginitis were slightly over three weeks apart. The next two bouts were a full three months apart. Her last bout came six months later. Simultaneously, Pat and Gary mellowed-as individuals and as a couple. Midway through the post-therapy year, they married, and at the end of it, Gary came to my laboratory and said, "You know what? I believe you! I'm here for testing and for the therapy, if I need it." Gary did need antibiotic therapy, and I prescribed the same therapy for him I'd given Pat. I also advised them to continue using a condom during sexual intercourse. No course of treatment for bacterial contamination is 100 percent certain, and with an infection as disruptive as Pat's had been, I didn't feel they should take any chances.

PREMENSTRUAL SYNDROME

Unfortunately, Gary's reluctance to admit he was part of Pat's problem typifies the ambivalent response of far too many men to their female partners' reproductive difficulties-indeed, to female sexuality in general. In no other context is this more apparent than in the tendency among men to dismiss PMS as a valid physical complaint. That the controversy around PMS continues to rage also exemplifies our culture's willful blindness toward all genital-tract problems. The name itself is a model of vagueness and evasion, and the symptoms-a complex of physical, emotional, and behavioral disorders beginning in the second part of the menstrual cycle and ending soon after menstruation-are often not taken seriously. Thus, PMS is a stand-up comic's delight, immediately provoking nervous laughter as performers conjure up demeaning images of deranged harpies or self-destructive hypochondriacs.

In fact, the problems characterizing most cases of PMS are fairly mundane in themselves. They include any combination of the following maladies: breast tenderness, increased appetite, craving for food (especially food with high carbohydrate levels), abdominal bloating, fatigue, headaches, emotional instability, loss of interest in sex, depression, anxiety, restlessness, irritability, hostility, or aggression. And for all the mystery associated with PMS (part of which is certainly due to centuries of inattention), the problems it can bring are very real and very widespread in the population. Experts estimate 90 percent of women experience one or more symptoms of PMS during their reproductive years. Within this group, 30 percent endure chronic, life-disrupting symptoms, and 5 percent are seriously incapacitated on a regular basis.

Aside from making the sufferer herself uncomfortable, PMS can wreak havoc on everyone around her. The adverse behavior it generates can disrupt family life, strain friendships, and sour working relationships. Under extreme conditions, it can even lead to such tragedies as divorce, child abuse, and violent assault.

To date, the precise causes of PMS have not been conclusively proved, and so there is no definitive cure. My own professional experience, however, leads me to believe that a high percentage of PMS cases are either directly caused or aggravated by a bacterial infection in the reproductive tract most likely an endometrial or ovarian infection.

As often happens to clinical doctors, I deduced a possible cause after stumbling upon an evident cure. Many female infertility patients whom I had treated with broad-spectrum antibiotics confessed without prompting that their PMS symptoms thereafter were significantly and permanently alleviated. I inferred from their testimony that their PMS, along with their infertility, had been reversed through exposure to the antibiotics.

Several colleagues shared my hypothesis. Together, we designed and conducted an experiment in 1986 to test whether antibiotic therapy could offer measurable and lasting relief to PMS sufferers.

Our first challenge was to locate subjects whose PMS might be linked to bacterial infection. A newspaper advertisement was used to recruit a random cross section of candidates. From these respondents, we selected only those who were otherwise healthy and who had not taken antibiotics or any other strong medication during the previous year. Next, we disqualified any candidate who could not trace the onset of her PMS symptoms (as listed above) to a particular sexual encounter, a pregnancy-related D and C, a miscarriage, an ectopic pregnancy, or childbirth - events during which bacteria would have had a chance to invade the genital tract.

Those candidates who remained were asked to evaluate their particular symptoms daily for one complete menstrual cycle, rating each symptom on a scale of zero to ten (ten being the most highly symptomatic). If the daily average sum of a candidate's symptoms during the last six days of her cycle exceeded at least twice the daily average sum of her symptoms from days 6 through 10 of her cycle, then she would be eligible for the study. This basic test, incidentally, is a good way for women in general to begin determining whether or not they may be suffering from PMS.

Ultimately, we found thirty ideal subjects, all of whom claimed that their PMS symptoms noticeably interfered with their daily social and professional activities. For the duration of the study, they agreed to avoid any other medications stronger than aspirin or acetaminophen and to maintain phone contact with us-a means of ensuring their compliance with the experimental protocol. If a subject was sexually active, her partner had to agree either to use condoms or join in the treatment regimen.

The first month of the experiment consisted of drug-free self-evaluation. Each woman kept a daily record of her symptoms, similar to the record she had kept immediately prior to the experiment, plus she filled out a detailed questionnaire regarding her menstruation: the number of days, the consistency of the flow (spotty, light, medium, heavy), the color of the flow (brown, light red, dark red) and the overall severity of pain each day of the menses (on a scale of zero to ten, with ten the most painful).

At the start of the second month, the thirty subjects, continuing to monitor their symptoms day by day, were randomly divided into two treatment groups. Each subject received a supply of 100-milligram capsules to be taken orally twice a day, but the capsules for one group contained a placebo (a neutral, ineffectual substance), while the capsules for the other group contained an antibiotic (doxycycline). All the capsules, identical in appearance, were prepared and "randomized" by the New York Hospital's pharmacy, which kept the identification codes sealed until this stage of the experiment was over. Thus, we had a more credible, double-blind trial; that is, neither we, the conductors of the experiment, nor the subjects knew at the time who had been given the placebo and who had been given the antibiotic.

At the end of the second month, the codes were opened, and the antibiotic was administered to those individuals who had been taking the placebo. This group went through another month of the same protocol. During each month of the experiment (two months for the women who had initially received the antibiotic, three months for the women who had initially received the placebo), all subjects were tested in the laboratory at appropriate points in their menstrual cycle for hormonal levels and bacteria. All subjects also participated in a six-month follow-up, which consisted of keeping a record of an entire menstrual cycle as a final evaluation document and imposing upon themselves the same restrictions that had applied earlier.

The bottom-line information we gained from this experiment is extremely heartening. At the end of the second month, we discovered that those women who had taken the antibiotic had experienced a dramatic improvement in their PMS symptoms while those who had taken the placebo had displayed no significant changes. After switching to doxycycline for the third month of the experiment, the former placebo takers registered the same high degree of improvement as their counterparts had. Six months later, a survey of all thirty subjects reported greatly reduced PMS difficulties across the board.

Three years following the conclusion of the therapy, I managed to interview twenty of our original subjects. Seven of these individuals enjoyed permanent improvement and were practically free of PMS symptoms. Unfortunately, the other thirteen gradually developed certain PMS symptoms, if not the full-blown syndrome, all over again. When I discussed our newer intravenous antibiotic treatment regimen, five of the thirteen reported for treatment courses. A look at the bacteriological isolates from these five patients revealed only anaerobic organisms from the initial culture studies-organisms on which doxycycline does not have a full-spectrum effect.

After concluding intravenous clindamycin and gentamicin courses, all five women responded with marked improvement in their PMS symptoms. Four of these women have so far remained symptom-free. One of them has remained symptom-free following a second course of the clindamycin and gentamicin intravenous treatment.

PMS continues to be a mystery inviting new theories and new treatment approaches. Mild sufferers get some relief from experimenting with self-help programs that include a restricted diet (frequent, small meals low in salt, sugar, caffeine, and alcohol), regular exercise, and ongoing stress-management techniques. Most serious sufferers, however, require medical assistance to overcome their symptoms.

Some doctors today advise altering the brain chemistry with "mood" or "diet" drugs, but this takes care of only those symptoms that are emotional in nature. Other doctors favor stopping ovulation altogether with drugs or surgery (usually by removing the ovaries, but sometimes by performing a hysterectomy). Obviously, this engineered end of menstruation means the end of PMS, but at a drastic price.

The 1987 study conducted at my laboratory does not, by any means, solve the mystery of PMS once and for all, but it does point to a promising new era in which PMS treatment for some women may not have to be so makeshift or hazardous. In the first place, the study suggests that the underlying cause of troublesome PMS symptoms in a significant number of patients may, indeed, be bacterial infection. Among the thirty subjects in the study, an unexpectedly high percentage of their endometrial biopsy cultures yielded positive findings for chlamydia, mycoplasma, and/or anaerobic bacteria. In the second place, the study suggests that low-risk, highly controllable antibiotic treatment is able to reverse troublesome PMS symptoms permanently.

Now, in the day-to-day activities of many of those women who participated in the study, freedom from their PMS symptoms translates into greater comfort, enhanced pleasure, and improved productivity. What gratifies me even more, however, is that antibiotic therapy revived their healthy pelvic function.

PELVIC INFLAMMATORY DISEASE

Like premenstrual syndrome, pelvic inflammatory disease (PID) is a clinical catchall title for an ill-defined malady. There is no symptom that clearly indicates the beginning of the illness, nor is there any certainty regarding what factors might turn a mild, subclinical condition into a clinically manifested, destructive process.

By strict definition, PID refers to any inflammation inside the pelvic cavity; thus, from a physiological standpoint, illnesses such as vaginitis, cervicitis, endometritis, salpingitis, and oophoritis are mere subcategories of PID. In medical practice, however, the diagnosis PID is reserved for relatively severe inflammations of the upper reproductive tract: the uterus, the fallopian tubes, and the ovaries.

PID is almost always set into motion by STDs-chief among them chlamydia and, anaerobic bacterial infections. It is especially prevalent among women who first began having sexual intercourse at an early age, who have a history of multiple sexual partners, or who have relied on IUDs for birth control. The fact that IUD users are seven to ten times more likely to develop PID than women using barrier-type birth control methods is a strong indicator that PID is inclined to result from exposure to a male partner's seminal fluid during sexual intercourse.

In the typical PID case, harmful bacteria enter the upper part of the female genital tract, and the subsequent infection makes it easier for the native bacterial flora to proliferate and intensify the damage. Spermatozoa serve as an important vector in bacterial transfer. In those rare cases when a sexually abstinent woman develops PID, it is presumably because infectious bacteria-acquired during prior, sexually active years or via vertical transmission-have ascended through her genital tract during menstruation. In even rarer cases, bacteria from organs adjacent to the reproductive tract (such as the appendix or the bowels) can trigger a PID-causing infection.

As the most widespread and serious complication of sexually transmitted diseases, PID today is a medical and public health problem of rapidly escalating proportions. Experts claim that more than one million American women experience palpable symptoms of PID each year. Assuming 50 percent of all PID cases are asymptomatic, the number of actual PID victims would be twice as high. At least one third of the documented PID patients are eventually rendered infertile, and in 1989 alone (the last year for which estimates are available), the cost of treating PID and its consequences in the United States totaled over three billion dollars

Much more worrisome than the monetary cost of PID is its cost in human misery. The typical PID symptom is mild lower abdominal discomfort or tenderness, but in bad cases, the pain grows noticeably worse over several days, perhaps becoming so strong that the victim has difficulty walking, urinating, or doing much else beyond merely enduring. At this point, treatment is mandatory. Otherwise, the infection could breed an abscess, which might burst and send life-threatening infectious pus throughout the woman's abdominal cavity.

One night last year, Nora entered a local hospital emergency room with acute pain all across her abdomen and an enlarged mass on the left side of her pelvis. The initial interview revealed that she had been sexually active with one man for the last four months, had not used birth control, and had engaged in unusually strenuous sexual intercourse immediately before being taken to the emergency room by her partner.

Since Nora's vital signs were stable and she showed only a slight temperature, the problem was diagnosed and treated as a ruptured ovarian cyst. The attending doctor assumed the swelling in her pelvis was caused by blood. She spent a week in the hospital and was released.

I wound up taking over Nora’s case shortly after her hospital stay, when her only complaint was a "slight tenderness in the abdomen or stomach, nothing much." Right from the start, I suspected her troubles were due to PID, not simply a ruptured ovarian cyst, and so I requested a sonogram. It confirmed my suspicion. One of her fallopian tubes was widely dilated and full of pus. Her ovary was swollen and full of cysts.

During the brief period of time involved in taking and interpreting the sonogram, Nora's pain steadily increased. Within a week, she developed a slight fever and, again, a small swelling in her pelvis that seemed to be caused by a fluid of some sort. Meanwhile, I analyzed her bacteria culture and I found large amounts of chlamydia.

Nora's culture results, coupled with her latest symptoms, convinced me she was suffering from an advanced case of PID and that the fluid in her pelvis was due to the inflammation. I put her on a six-week doxycycline/erythromycin regimen and treated her partner with the same medication. She became symptom-free halfway into this therapy, and the results of her subsequent pelvic cultures were negative.

In Nora's case, a well-informed and well-conducted initial interview may have established the cause of her problem earlier, thus saving her a great deal of pain, time, trouble, and expense. The case of Sandy illustrates how proper history taking can aid a doctor in making a timely diagnosis of PID. I was on call for the hospital one night when the chief resident summoned me to give an opinion about a woman who had just been admitted to the emergency room and was in her twenty-fourth week of pregnancy. Surgical colleagues had already seen Sandy, had diagnosed tenderness in the area of her appendix and had recommended surgical exploration and a possible appendectomy. They wanted my input concerning the advisability of immediate surgery.

When I arrived at the hospital, the operating room had been fully prepared, and Sandy was ready to be taken upstairs for surgery. Simply approaching her from a distance, I observed that her midsection was much smaller than one would expect at the twenty-fourth week of a pregnancy. I couldn't help thinking that perhaps implantation had occurred in an already contaminated uterus, and now the fetus, deprived of nutrients, was lagging behind in development.

I proceeded to question her even before examining the lower right quadrant of her abdomen (where the appendix lies). As it turned out, this was Sandy's third pregnancy. The first one had taken place a few years back and had been interrupted after only six weeks. When we started discussing the second pregnancy which had resulted in the birth of a boy, I chose my questions carefully to elicit possible evidence that the second pregnancy had taken place in a contaminated uterus.

"Was your son born either a few weeks prematurely or a few weeks late?" I asked.

"Yes," Sandy replied. "He was born six weeks before his due date."

Next I asked, "Am I correct in assuming that your son, was born at a lower birth weight than you anticipated, even considering his prematurity?" Sandy's answer was again affirmative.

I went on to ask questions relating to the health of Sandy's son. Much to her amazement, I was right in my conjectures. Yes, her son was asthmatic. Yes, he had chronic ear infections. Yes, he had had a tonsillectomy at an early age.

At this point, I suspected that both the difficulties associated with the child's birth and his subsequent health problems could be traced to a contaminated uterine cavity. Most likely, the contamination had originally occurred at the time of Sandy's first pregnancy or shortly thereafter.

Then I asked Sandy's husband, Jack, whether he noticed any change in Sandy's personality after the birth of their son. "Yes, indeed!" Jack answered. "Not only was she more moody in general, but she'd throw tantrums every now and then, usually right before her period. We almost split up a couple of times because of these tantrums."

Sandy confirmed what Jack told me. When I asked her if there were any observable changes in her menstrual flow after giving birth, she nodded. "Before, my period used to last six or seven days," she recalled, "and there was a lot of bright, red blood. Afterward, it dwindled down to just a couple of days, with hardly any blood at all."

I was now convinced Sandy's current pregnancy was conceived in a highly unfavorable environment, where an ample number of bacteria were ready to cause a serious infection, given the opportunity. The pregnancy gave the bacteria that opportunity. The tenderness in her abdomen, I thought to myself, was not due to an inflamed appendix but to an infected fallopian tube. Turning to a nearby resident, who was obviously confused by the nature and meaning of my questions, I said, "Please cancel the surgery and call the chief resident."

When the chief resident came to the telephone, I told her I believed Sandy's problem was pelvic inflammatory disease specifically, salpingitis. Rather than surgical intervention, I advised overnight intravenous administration of cefoxitin a broad-spectrum antibiotic that would be perfectly safe for Sandy and her unborn child at this stage of the pregnancy. After a short argument, the chief resident consented to implement this course of treatment if I would take full responsibility.

About four days later, I met the chief resident in a hospital hallway. When I inquired about the follow-up to Sandy's antibiotic treatment, she said, "Well, after four more days of intravenous erythromycin, we discharged the patient, symptom-free."

"Why erythromycin?" I asked.

"The morning after she was admitted," the chief resident replied, "we got a positive confirmation of chlamydial infection in the patient's cervix." Thus, my hypothesis of PID due to bacterial infection was confirmed, and luckily for Sandy, no unnecessary surgery took place.

Sandy's case well illustrates the value of taking time to ask a patient questions. This common-sense but often overlooked strategy can lead to a much more accurate diagnosis, even before the results of laboratory work are available. Sandy's case also exemplifies the importance of exploring every possible avenue of questioning instead of leaping to conclusions. Despite the fact that pregnancy is rarely associated with such a dramatic flare-up of PID, the possibility cannot be ignored.

In the absence of gross symptoms like the ones Nora and Sandy exhibited, it is not always possible to detect the presence of PID in a woman's reproductive system. Even assuming medical science could do so, it is not practical to test on a routine basis every suspected high-risk individual. The cost to the patient-financially, physically, and emotionally-of performing a laparoscopy and culturing tissue samples is prohibitive.

The answer to this dilemma for millions of specific individuals and for public health in general lies in a more concerted effort to recognize, avoid, and solve reproductive health problems before they become so threatening. In the next chapter, I'll consider possible ways of making this important effort.

To Chapter 6: Breaking the Circle: The Fertile Future