It was a community based cross-sectional study. All the households registered under Urban Health and Training Centre (UHTC) and Rural Health and Training Centre (RHTC), Department of Community Medicine, JN Medical College, Aligarh, Uttar Pradesh, India was taken under the sampling frame. The study period was one year i.e., from June 2012 to May 2013. All postmenopausal women who had completed at least one year of menstruation free period were included. Women who did not give consent, those who had not attained menopause, those who were receiving hormone replacement therapy and those who were suffering from severe, debilitating illness were excluded [16,17].

Systematic random sampling and proportionate to Population Size Method (PPS) were used. The distribution of sample with respect to the areas has been shown in [Table/Fig-1]. The sample size was taken according to the study conducted by Puri S et al., in the urban and slum areas of Chandigarh, Punjab, India, where out of 71.4% of the total females who had attained menopause at the time of study, 42.7% had vaginal irritation/discharge, which was used for calculating the sample size for this study [18]. The total sample size was calculated according to the formula;

N = z²pq/L²

where z=1.96, p stands for prevalence (42.7%), q = 100- p, L = relative error = 15% of p, the corrected sample size was 262.

Considering design effect and taking equal sample size from rural as well as urban areas, a total of 530 postmenopausal women were approached. Informed and written consent was taken. The study tool comprised of pre tested and pre structured proforma with information about personal details including the name, age, address, marital status, religion, occupation, educational status, total family income, type of family, place of residence, locality etc., and detailed history of uro gynaecological complains, if present. The locality of the area was assessed as congested by the number of houses in the given area and presence of other houses on all three sides [9]. If there were any complains suggestive of PID, patients were taken for gynaecological examination at the respective centres. Abdominal examination and local gynaecological examinations were done. The cervical discharge was collected by three different techniques for pathological and microbiological investigations.

With the first technique, cotton swab was introduced for collection of discharge on two slides for wet mount smear method (for isolation of protozoa) and 10% Potassium Hydroxide (KOH) application test (for isolation of Candida and for Whiff’s test).

With the second technique, a cervical swab culture stick was introduced for culture and sensitivity and for gram staining. With the third technique, an Ayre’s spatula was introduced for making a Papanicolaou (Pap) smear slide.

The presence of PID was confirmed by microscopic and histopathology Pap examinations. Bacterial vaginosis is a poly microbial disorder characterized by an increase in the vaginal pH over 4.5, a reduction in or absence of colonization of lactobacilli on the vaginal mucosa and overgrowth of several facultative and obligate anaerobic bacteria. Its diagnosis was made by the presence of a minimum of 20% of “clue” cells in the squamous cell population on microscopic examination of a saline suspension of vaginal discharge, associated with two of the following three findings [18]:

The Pap smear slide was sent to the department of pathology after fixing in 10% formaldehyde. The cervical swab culture was sent to the department of microbiology in standard culture bottles for Gram staining, culture and sensitivity. Wet mount smear method was used for isolation of Trichomonas vaginalis. 10% KOH application was used for isolation of Candida with the help of microscope. Whiff’s test was used for detecting Gardenella vaginalis, confirmed by the presence of clue cells on wet mount examination, confirmed by the presence of clue cells on wet mount examination. These were done in the respective labs of UHTC and RHTC. Various parameters of relevance along with socio-demographic profile of patients were studied and correlated with the above findings. The diagnosis of urinary tract infection was confirmed by microscopic examination of urine. The diagnosis of pelvic organ prolapse was made by clinical examination by a trained gynaecologist at the respective centres.

Data was analyzed using the SPSS version 23.0. Standard error of difference between the two proportions, chi-square test and logistic regression analysis was applied wherever applicable. The value of p<0.05 was considered as significant for this study.

Ethical considerations: Informed written consent was taken from each subject before interview. Health education and counselling regarding the risk factors for development of different problems were provided to all the respondents. Permission from the Institutional Ethics Committee, Faculty of Medicine, AMU, Aligarh, Uttar Pradesh, India, was taken. Management or referral of the patients was done at the respective centres wherever needed as per requirement.

The mean age of the study population was 58.14±8.45 years. Median age was 57.0 years and mode was 50.0 years. Out of the 530 post menopausal women, 385 were having a gynaecological or urinary complain. A total of 219 (41.3%) complained of increased frequency, 116 (21.9%) complained of pain/burning micturition, 60 (11.3%) complained of discharge per vaginum out of which 41 (7.7%) said it was foul smelling, 195 (36.8%) had lower abdominal pain and 21 (3.9%) vaginal itching. These were examined by a gynaecologist and confirmatory diagnosis was made in 61 women after laboratory examination results. The average prevalence of PID was found to be 11.55% with 12.5% in rural areas and 10.6% in urban areas [Table/Fig-2]. It varied over the different age groups and the prevalence was seen to be increasing with age.

[Table/Fig-2]:

Prevalence of PID compared with area of residence.

As seen in [Table/Fig-3], higher prevalence was found in rural areas compared to the urban areas. This difference in prevalence of PID over age groups in rural and urban areas was found to be significant (p<0.05). The difference with respect to occupation was found to be significant. The personal habits of the study subjects were analyzed for the presence of risk factors and it was found that presence of obesity, smoking habits and tobacco chewing were not found to be significantly associated.

PID is a predominately reproductive age illness and its highest prevalence is in the second and third decades of life. It is a very uncommon diagnosis in menopause. It is estimated that less than 2% of patients admitted to hospitals for salpingitis and tubo-ovarian abscess are postmenopausal [6]. In the present study, the average prevalence of PID was found to be 11.55% with 12.5% in rural areas and 10.6% in urban areas [Table/Fig-1,2]. It needs to be emphasized that no similar study has been done in the area before, so baseline measures for comparison are seriously inadequate.

Cervico-vaginal flora in postmenopausal women: In the present study, the cases were first screened on the basis of history and then confirmatory diagnostic methods were done. Apart from early studies very few reports on both the aerobic and anerobic flora of postmenopausal patients have been published. It is suggested by the literature review that menopause results in decrease in lactobacillus colonization.

A study done to reveal upper vaginal and cervical bacterial flora in menopausal women found majority of the culture samples to be sterile. One study reported that vaginal flora of menopausal women is not different from that found in children, young women, in pregnancy or postpartum. They documented that anaerobic germs isolated in their study are normal inhabitants of the vagina and cervix which may occasionally become pathogens [19]. According to the study by Tashijan JH et al., lactobacilli were the most commonly detected organism in postmenopausal group of study subjects [20]. Hillier SL et al., studied the vaginal microflora of postmenopausal women who had never received oestrogen replacement therapy and found Lactobacilli, Gardnerella vaginalis and coliforms [19]. The prevalence of bacterial vaginosis found in the present study (4.1%) is similar to that found by Cauci S et al., who reported that the prevalence of bacterial vaginosis was significantly lower overall in postmenopausal women (6.0%) (p=0.02) [21].

Risk factors for PID: Older women do not usually have risk factors, which can expose them to sexually transmitted microorganisms. With advancing age there are behavioural, physiologic and anatomic alterations that offer barriers to the usual means of developing PID. Uterine instrumentation is a risk factor associated with the development of PID in the postmenopausal woman [22]. Structural abnormalities of the genital tract, such as cervical stenosis, uterine anatomic abnormalities, and tubal disease, are also associated with an increased risk of developing PID. On pelvic examination, palpable indurated masses may be present, suggesting a possible genital tract malignancy [6]. The present study determined the association of prevalence of PID in postmenopausal women with smoking and chronic diseases, and did not find a significant association. A meta-analysis done to find out the factors responsible for chronic pelvic pain showed that it is predisposed by smoking, increased parity and chronic conditions although this study was not specific for postmenopausal women [23,24].

In our study, we examined only the symptomatic women for clinical and laboratory examinations. This is a definite limitation of the study as a lot of women present in the community might be asymptomatic and harbouring the disease in its early stages. Better diagnostic modalities like ultrasonography could not be incorporated in the study due to increased cost.

Pelvic inflammatory disease is a significant public health issue with certain repercussion on women’s health and wellbeing in the long run. The study shows the hidden burden of the disease in the community and the associated risk factors, which can be prevented by life style and cultural changes if incorporated earlier in the lives. There is a pressing need to create awareness among the women of the community regarding the identification and early reporting of symptoms. Other than the chronicity of lower abdominal pain ruining the wellbeing of the affected women, infertility and the associated stigma, the absolute dearth of literature on the subject compounds the need to study this issue in developing countries.