Emergency departments still missing signs of pelvic disease in teens

Despite government efforts to expand diagnostic criteria for pelvic inflammatory disease, emergency department doctors are not identifying the condition any more often in adolescent girls, finds a new study in Journal of Adolescent Health.

Pelvic inflammatory disease, or PID, is a complication of sexually transmitted infections, such as chlamydia or gonorrhea. PID disproportionately affects teen girls and young women.

Unfortunately, doctors often miss the diagnosis. Early diagnosis is important, since if left untreated, PID can result in infertility, chronic pelvic pain, pelvic abscesses, and other serious conditions. To help doctors identify PID earlier, the Centers for Disease Control and Prevention (CDC) broadened the diagnostic criteria for the condition in 2002.

Monika Goyal, M.D. and colleagues looked at data from the 2000-2009 National Hospital Ambulatory Medical Care Survey. Of an estimated 77 million emergency department visits by 14- to 21-year-old adolescents, there were approximately 705,000 diagnosed cases of PID. "We found there was a slight but not significant decrease in the diagnosis rate after the revised CDC criteria were published," said Goyal, a pediatrician at the Children's National Medical Center in Washington, DC.

"Based on these findings, it's hard to know what exactly is going on," Goyal said. "We don't know if it's because PID has definitely declined or because we're just not thinking about it as much as we should. One of our concerns is we are still missing girls that have PID."

"It's hard to tell exactly why there was no significant change. I think it's a combination of things. When the CDC broadened the criteria in 2002, it was because doctors were missing 15 percent of PID cases. So there is probably still some of that going on," commented Angela Diaz, M.D., program and research director of Mount Sinai's Adolescent Health Center in New York City.

Diaz also said that even when new diagnostic guidelines are put into place, not all providers are aware of the changes or may not implement the changes.

Both Goyal and Diaz said it is also possible that with increased screening rates for chlamydia—which doubled between 2000 and 2010 from 25 percent to 48 percent among young women—adolescents are being treated in other outpatient settings before signs of PID develop.

Still, 70 percent of adolescent patients with PID are diagnosed in the emergency department, which is arguably not the best place for managing adolescent sexual health. Research has found that many emergency department doctors are unable to accurately diagnose PID and feel uncomfortable performing pelvic exams on adolescent females.

"With healthcare reform and more young people getting health insurance, I am hoping they will have better access to primary care, including screening and treatment for sexually transmitted infections, more education of young people about preventing these diseases and better training of the doctors who diagnose PID," Diaz said.