Analysis of Neutrophil-To-Lymphocyte Ratio (NLR) Examination Results in Patients with Pelvic Inflammatory Disease (PID)
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Abstract
Pelvic Inflammatory Disease (PID) is a polymicrobial infection of the upper genital tract that can lead to serious complications such as infertility due to tubal damage, ectopic pregnancy, and chronic pelvic pain. Diagnosing PID is often challenging because its symptoms are nonspecific and there is no single accurate laboratory marker. One biomarker that has increasingly gained attention is the Neutrophil-to-Lymphocyte Ratio (NLR) as an indicator of systemic inflammation. This literature review aims to evaluate the diagnostic value of NLR in patients with PID through an analysis of clinical and mechanistic studies. Literature searches were conducted using the PubMed, Scopus, and Google Scholar databases. The results show that NLR is significantly elevated in patients with PID compared to healthy controls, reflecting the predominance of acute inflammatory processes characterized by increased neutrophils and decreased lymphocytes due to immunological stress. The Neutrophil-to-Lymphocyte Ratio (NLR) is an accurate inflammatory marker with high sensitivity and specificity; it is simple, inexpensive, and accessible through routine blood tests, making it a potentially valuable diagnostic tool for Pelvic Inflammatory Disease (PID).
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References
I. He D, Wang T, Ren W. Global burden of pelvic inflammatory disease and ectopic pregnancy from 1990 to 2019. BMC Public Health. 2023 Dec 1;23(1).
II. Ye H, Tian Y, Yu X, Li L, Hou M. Association Between Pelvic Inflammatory Disease and Risk of Endometriosis: A Systematic Review and Meta-Analysis. J Womens Health (Larchmt). 2024 Jan;33(1):73–9.
III. Maqsood N, Daniel J, Forsyth S. The Risk of Pelvic Inflammatory Disease in Women Infected With Chlamydia (Chlamydia trachomatis): A Literature Review. Cureus. 2024 Aug 6;
IV. Turgut A, Akdeniz E, Usta A, Ersahin AA, Karateke A, Hocaoglu M. Predictive value of neutrophil to lymphocyte ratio, lymphocyte to monocyte ratio and mean platelet volume for pelvic inflammatory disease. Clin Exp Obstet Gynecol. 2019;46(1):36–41.
V. Akopuz A, Turan V, Ozcan A, Kopuz Y, Toz E, Kurt S. A novel marker for the assessment of the treatment result in pelvic inflammatory disease. Minerva Ginecol. 2016 Apr;68(2):117–23.
VI. Xie C, Tang B, Wu K, Meng Q, Wang F. Increased serum LOXL2 concentration in pelvic inflammatory disease with pelvic adhesion. BMC Womens Health. 2022 Dec 1;22(1).
VII. Soputri N, Ratuningrum R, Tri A, Supriarti M, Sri N, Sirait H, et al. Masalah dan Gangguan Pada Sistem Reproduksi. Oktavianis, editor. Get Press Indonesia; 2025.
VIII. Aliyeva S, Kaya S, Soyman Z, Ateşer G, Bacanakgil H, Boran B. Diagnostic Value of Hematological Parameters in Pelvic Inflammatory Disease. Istanbul Medical Journal. 2019 Oct 24;20(5):482–6.
IX. Yang C, Lei L, Collins JWM, Briones M, Ma L, Sturdevant GL, et al. Chlamydia evasion of neutrophil host defense results in NLRP3 dependent myeloid-mediated sterile inflammation through the purinergic P2X7 receptor. Nat Commun. 2021 Dec 1;12(1).
X. Diksha Jawale, Shweta Khandibharad, Shailza Singh. Innate Immune Response and Epigenetic Regulation: A Closely Intertwined Tale in Inflammation. Adv Biol. 2024;9(2).
XI. Costa-Fujishima M, Yazdanpanah A, Horne S, Lamont A, Lopez P, Farr Zuend C, et al. Nonoptimal bacteria species induce neutrophil-driven inflammation and barrier disruption in the female genital tract. Mucosal Immunol. 2023 Jun 1;16(3):341–56.
XII. Ling H, Luo L, Dai X, Chen H. Fallopian tubal infertility: the result of Chlamydia trachomatis-induced fallopian tubal fibrosis. Vol. 477, Molecular and Cellular Biochemistry. Springer; 2022. p. 205–12.
XIII. Ball LM, Bronstein E, Liechti GW, Maurelli AT. Neisseria gonorrhoeae drives Chlamydia trachomatis into a persistence-like state during in vitro co-infection. Infect Immun. 2024 Jan 1;92(1).
XIV. Tabbalat AM, Sheriff MZM, Chak AM. S2884 Pelvic Inflammatory Disease as an Unusual Cause of Ascites. Am J Gastroenterol. 2021;
XV. David E Soper, Harold C Wiesenfeld. The Continued Challenges in the Diagnosis of Acute Pelvic Inflammatory Disease: Focus on Clinically Mild Disease. J Infect Dis. 2021;224(2):S75–9.
XVI. Darville T. Pelvic Inflammatory Disease Due to Neisseria gonorrhoeae and Chlamydia trachomatis: Immune Evasion Mechanisms and Pathogenic Disease Pathways. Journal of Infectious Diseases. 2021 Aug 15;224:S39–46.
XVII. Mitchell CM, Anyalechi GE, Cohen CR, Haggerty CL, Manhart LE, Hillier SL. Etiology and Diagnosis of Pelvic Inflammatory Disease: Looking beyond Gonorrhea and Chlamydia. In: Journal of Infectious Diseases. Oxford University Press; 2021. p. S29–35.
XVIII. Lei W, Wen Y, Yang Y, Liu S, Li Z. Chlamydia trachomatis T3SS Effector CT622 Induces Proinflammatory Cytokines Through TLR2/TLR4-Mediated MAPK/NF-κB Pathways in THP-1 Cells. Journal of Infectious Diseases. 2024 Jun 15;229(6):1637–47.
XIX. Xiang W, Yu N, Lei A, Li X, Tan S, Huang L, et al. Insights Into Host Cell Cytokines in Chlamydia Infection. Vol. 12, Frontiers in Immunology. Frontiers Media S.A.; 2021.
XX. Wang X, Wu H, Fang C, Li Z. Insights into innate immune cell evasion by Chlamydia trachomatis. Vol. 15, Frontiers in Immunology. Frontiers Media SA; 2024.
XXI. Belcher T, Rollier CS, Dold C, Ross JDC, MacLennan CA. Immune responses to Neisseria gonorrhoeae and implications for vaccine development. Vol. 14, Frontiers in Immunology. Frontiers Media SA; 2023.
XXII. Xu SX, Gray-Owen SD. Gonococcal Pelvic Inflammatory Disease: Placing Mechanistic Insights into the Context of Clinical and Epidemiological Observations. Journal of Infectious Diseases. 2021 Aug 15;224:S56–63.
XXIII. Mbah CE, Jasani A, Aaron KJ, Akoachere JF, Tita ATN, Geisler WM, et al. Association between Chlamydia trachomatis, Neisseria gonorrhea, Mycoplasma genitalium, and Trichomonas vaginalis and Secondary Infertility in Cameroon: A case-control study. PLoS One. 2022 Feb 1;17(2 February).
XXIV. Mohamed AAA. Pelvic inflammatory disease: clinical feature, risk factors, treatment, and prevention. Vol. 36, Indian Journal of Community Health. Indian Association of Preventive and Social Medicine; 2024. p. 769–77.
XXV. Htaik K, Vodstrcil LA, Plummer EL, Sfameni AM, Machalek DA, Manhart LE, et al. Systematic Review and Meta-analysis of the Association Between Mycoplasma Genitalium and Pelvic Inflammatory Disease (PID) . Clinical Infectious Diseases. 2024 Jun 7;
XXVI. Cheng C, Chen X, Song Y, Wang S, Pan Y, Niu S, et al. Genital mycoplasma infection: a systematic review and meta-analysis. Vol. 20, Reproductive Health. BioMed Central Ltd; 2023.
XXVII. Manhart LE, Leipertz G, Soge OO, Jordan SJ, McNeil C, Pathela P, et al. Mycoplasma genitalium in the US (MyGeniUS): Surveillance Data From Sexual Health Clinics in 4 US Regions. Clinical Infectious Diseases. 2023 Nov 15;77(10):1449–59.
XXVIII. Jeong S, Tollison T, Brochu H, Chou H, Huntress I, Yount KS, et al. Cervicovaginal microbial features predict Chlamydia trachomatis spread to the upper genital tract of infected women. Infect Immun. 2025 Sep 1;93(9):e0005725.
XXIX. Yount KS, Darville T. Immunity to Sexually Transmitted Bacterial Infections of the Female Genital Tract: Toward Effective Vaccines. Vol. 12, Vaccines. Multidisciplinary Digital Publishing Institute (MDPI); 2024.
XXX. Tabatabaei F, Babadi S, Nourigheimasi S, Ghaedi A, Khanzadeh M, Bazrgar A, et al. Neutrophil to lymphocyte ratio as an assessment tool to differentiate between uterine sarcoma and myoma: a systematic review and meta-analysis. BMC Cancer. 2024 Dec 1;24(1).
XXXI. Zhang F, Xia Y, Su J, Quan F, Zhou H, Li Q, et al. Neutrophil diversity and function in health and disease. Vol. 9, Signal Transduction and Targeted Therapy. Springer Nature; 2024.
XXXII. Mari A. Understanding pelvic inflammatory disease and endometriosis: Challenges and advances in management. Research and Reports in Gynecology and Obstetrics [Internet]. 2025;6(1):165. Available from: https://www.alliedacademies.org/research-and-reports-in-gynecology-and-obstetrics/
XXXIII. Dolui S, Manna S, Mandal A. Acute Pelvic Inflammatory Disease. Vol. 8, Eurasian Journal of Medicine and Oncology. Kare Publishing; 2024. p. 9–14.
XXXIV. Shibuki S, Saida T, Hoshiai S, Ishiguro T, Sakai M, Amano T, et al. Imaging findings in inflammatory disease of the genital organs. Vol. 42, Japanese Journal of Radiology. Springer; 2024. p. 331–46.
XXXV. Kerry-Barnard S, Zhou L, Phillips L, Furegato M, A Witney A, Sadiq T, et al. Vaginal microbiota in ethnically diverse young women who did or did not develop pelvic inflammatory disease: Community-based prospective study. Sex Transm Infect. 2022;98(7):503–9.
XXXVI. Venneri MA, Franceschini E, Sciarra F, Rosato E, D’Ettorre G, Lenzi A. Human genital tracts microbiota: dysbiosis crucial for infertility. Vol. 45, Journal of Endocrinological Investigation. Springer Science and Business Media Deutschland GmbH; 2022. p. 1151–60.
XXXVII. Patrelli TS, Franchi L, Gizzo S, Salvati MA, Berretta R, Piantelli G, et al. Can the impact of pelvic inflammatory disease on fertility be prevented? Epidemiology, clinical features and surgical treatment: evolution over 8 years. J Reprod Med. 2013 Sep;58(9–10):425–33.
XXXVIII. H.K Daglar, A. Kirbas, B. Kaya, F. Kilincoglu. The value of complete blood count parameters in predicting preterm delivery. Eur Rev Med Pharmacol Sci. 2016;20(5):801–5.
XXXIX. Moon HJ, Finney J, Ronnebaum T, Mure M. Human lysyl oxidase-like 2. Bioorg Chem. 2014;57:231–41.
XL. Cui L, Sheng Y, Sun M, Hu J, Qin Y, Chen ZJ. Chronic pelvic inflammation diminished ovarian reserve as indicated by serum anti mülerrian hormone. PLoS One. 2016 Jun 1;11(6).
XLI. Holub M, Beran O, Kaspříková N, Chalupa P. Neutrophil to lymphocyte count ratio as a biomarker of bacterial infections. Cent Eur J Med. 2012 Apr;7(2):258–61.
XLII. Obeagu EI, Obeagu GU. Leukocyte dynamics in female reproductive health: roles and mechanisms. Annals of Medicine & Surgery. 2025 Jun;87(6):3268–78.
XLIII. Di Tucci C, Di Mascio D, Schiavi MC, Perniola G, Muzii L, Benedetti Panici P. Pelvic Inflammatory Disease: Possible Catches and Correct Management in Young Women. Case Rep Obstet Gynecol. 2018 Jan 11;2018:1–4.
XLIV. Yildirim M, Turkyilmaz E, Avsar AF. Preoperative Neutrophil-to-Lymphocyte Ratio Has a Better Predictive Capacity in Diagnosing Tubo-Ovarian Abscess. . Gynecol Obstet Invest. 2015;80(4):234–9.
XLV. Ear T, McDonald PP. Cytokine generation, promoter activation, and oxidant-independent NF-κB activation in a transfectable human neutrophilic cellular model. BMC Immunol. 2008 Apr 11;9.
XLVI. Doğa Seçkin K, Karsli MF, Yücel B, Özköse B, Yildirim D, Aslan Çetin B, et al. Neutrophil Lymphocyte Ratio, Platelet Lymphocyte Ratio and Mean Platelet Volume; which one is More Predictive in the Diagnosis of Pelvic Inflammatory Disease? Gynecol Obstet Reprod Med . 2015;21(3):150–4.
XLVII. D. Retnoningrum, M.Hendrianingtyas, H. Istiadi, A. Jaludamascena. Correlation between Prolactin Serum with Neutrophil Lymphocyte Ratio (NLR) in Systemic Inflammatory Response Syndrome. Diponegoro International Medical Journal,. 2021 Apr;2(1):10–3.
XLVIII. de Jager CPC, van Wijk PTL, Mathoera RB, de Jongh-Leuvenink J, van der Poll T, Wever PC. Lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit. Crit Care. 2010 Oct 29;14(5).
XLIX. Vedavathi V, Veerabhadra Goud GK, Sudha V Patil, Rajeev Gandham. Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are useful markers of inflammation in polycystic ovary syndrome? Asian J Med Sci. 2023 Jun 1;14(6):99–103.
L. Herrera C, Tachedjian G, Institute B, Tingtao Chen A, Wessels JM, Gholiof M, et al. The female reproductive tract microbiotas, inflammation, and gynecological conditions. Frontiers in reproductive health [Internet]. 2022; Available from: https://app.Biorender.com/Biorender-templates.
LI. Kiran Kharsodiya, Kaushik Pratim Das, Harish Kumar Dhingra. Predictive value of IL-6, IL-1β, TNF-α, and vaginal pH in diagnosing vaginal microbial infections: A host-inflammatory axis perspective. J Microbiol Methods. 2025;237.
LII. Garcia EM, Lenz JD, Schaub RE, Hackett KT, Salgado-Pabón W, Dillard JP. IL-17C is a driver of damaging inflammation during Neisseria gonorrhoeae infection of human Fallopian tube. Nat Commun. 2024 Dec 1;15(1).
LIII. Silva NL da, Bitar AAB, Trombetta TC, Ribeiro AR, Bentes TK, Queiroz YS, et al. Association between Mycoplasma genitalium and pelvic inflammatory disease: systematic review. Research, Society and Development. 2023 Jan 21;12(2):e8812240030.
LIV. Yu J, Zhou Y, Luo H, Su X, Gan T, Wang J, et al. Mycoplasma genitalium infection in the female reproductive system: Diseases and treatment. Vol. 14, Frontiers in Microbiology. Frontiers Media S.A.; 2023.
LV. Sweeney S, Bateson D, Fleming K, Huston W. Factors associated with pelvic inflammatory disease: A case series analysis of family planning clinic data. Women’s Health. 2022;18.
LVI. Myo MG, Nguyen BT. Intrauterine Device Complications and Their Management. Curr Obstet Gynecol Rep. 2023 Apr 27;12(2):88–95.
LVII. Petousis S, Angelou P, Almperis A, Laganà AS, Titilas G, Margioula-Siarkou C, et al. Prophylactic Antibiotics before Gynecologic Surgery: A Comprehensive Review of Guidelines. Vol. 14, Journal of Personalized Medicine. Multidisciplinary Digital Publishing Institute (MDPI); 2024.