Endometritis – An Overview

Endometrium is penetrated by a diverse range of immunocompetent cells, including macrophages, natural killer cells, and T lymphocyte subsets, under normal settings. Throughout the menstrual cycle, the composition and density of endometrial immune capable cells changes. The tissue remodeling required to achieve endometrial receptivity is thought to be aided by such timed fluctuations in local leukocyte subpopulations.

Endometritis is an irritation or inflammation of the uterine lining (the endometrium). It usually happens after a woman has birth, although it can also happen to non-pregnant women. Inflammation of the endometrium can also affect the myometrium and, in rare occasions, the parametrium¹.

Causes²

• • • Endometritis is caused by an infection in the uterus.
    • It can be due to chlamydia, gonorrhea, tuberculosis, or a mix of normal vaginal bacteria.
    • It is more likely to occur after miscarriage or childbirth.
    • It is also more common after a long labor or C-section.
    • The risk of endometritis is higher after having a pelvic procedure that is done through the cervix. Such procedures include: D & C, Endometrial biopsy, Hysteroscopy, Placement of an intrauterine device (IUD)

Symptoms²

• • • Abdominal distension
    • Abnormal vaginal bleeding
    • Abnormal vaginal discharge -increased amount -unusual color , consistency or odor
    • Discomfort with bowel movement (including constipation)
    • Fever(range from 37.8 to 40˚C)
    • General discomfort, uneasiness, or ill feeling (malaise)
    • Pain in lower abdomen or pelvic region (uterine pain)

Acute endometritis ³

Microabscess development and neutrophil invasion in the endometrial superficial epithelium, gland lumina, and uterine cavity characterise acute endometritis.

Compromised abortions, deliveries, medical instruments, and the preservation of placental remnants are the most common reasons for organism isolation.

During acute endometritis, histologically, there is neutrophilic infiltration of the endometrial tissue.

The characteristic high temperature and purulent vaginal discharge are evident in the clinical presentation.

Menstruation is abnormally heavy following acute endometritis. Staphylococci, Streptococci, and N.gonorrheae are the most common causes.

Chronic endometritis ³

Endometrial superficial edematous alteration, high stromal cell density, dissociated maturation between epithelium and stroma, and infiltration of endometrial stromal plasmacytes are histopathologic characteristics.

The presence of plasma cells in the stroma distinguishes this condition.

Lymphocytes, eosinophils, and even lymphoid follicles can be observed, but without plasma cells, a histologic diagnosis is impossible.

Neisseria gonorrheae, Streptococcus, Chlamydia, Tuberculosis, Mycoplasma, and other organisms are most common.

Diagnosis³

• • • Microscopic examination is the gold standard
    • Hysteroscopic scoring systems have been proposed

• • • The health care provider will perform a physical exam with a pelvic exam.
    • the uterus and cervix may be tender, and the bowel sound  may be decreased. Patient may have cervical discharge.

The following tests may be performed:

• • • Cultures from the cervix
    • for chlamydia, Gonorrhea, and other organisms
    • Endometrial Biopsy
    • ESR (Sedimentation Rate)
    • Laparoscopy
    • WBC (White Blood Count)
    • Wet Prep (microscopic exam of any discharge)

Features: endometrial hyperemia (focal or diffuse), hemorrhagic spots, dilated endometrial vessels, micropolyps, endometrial polyp

Treatments for endometritis³

For acute endometritis

Oral antibiotics for mild disease (doxycycline / metronidazole, levofloxacin / metronidazole or amoxicillin / clavulanate) antiobiotics (such as gentamicin or clindamycin) if more severe.

For chronic endometritis

The therapy for is pharmacological and is based on the administration of broad-spectrum antibiotics

Generally, the drug of choice is doxycycline, administered in doses of 100 mg every 12 hours for 14 days, or alternatively, the administration of cephalosporins, macrolides, or quinolones also considered.

Where antibiotic therapy fails and/or where the presence of endometritis persists, an endo‐ metrial culture with a relative antibiogram should be considered and an appropriate antibiotic treatment regimen must be prescribed.

According to the Centres for Disease Control guidelines, the therapies recommended are in case of positive for Gram-negative bacteria: Ciprofloxacin 500 mg twice a day for 10 days as first line therapy

For gram-positive bacteria: Amoxicillin+clavulanate 1 g twice a day for 8 days; Mycoplasma and U. urealyticum infections: Josamycin 1 g twice a day for 12 days; while, in case of persistence, minocycline 100 mg twice a day for 12 days.

For negative cultures: Ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice a day for 14 days with metronidazole 500 mg orally twice a day for 14 days.

In case of persistence of signs of chronic endometritis at subsequent hysteroscopy, the protocol can be repeated up to three times. In the presence of confirmed tuberculous endometritis, the patient should be given a specific antibiotic therapy for tuberculosis (isoniazid, ethambutol, rifampicin, and pyrazinamide for 2 months, followed by isoniazid and rifampicin for another 4 months).

Endometritis caused by sexually transmitted infections can be prevented by

• • • Early diagnosis and complete treatment of sexually transmitted infections (STIs) in the patient and all sexual partners.
    • Following safer sex practices, such as using condoms.
    • The risk of Endometritis is reduced by careful, sterile techniques used by appropriate providers in performing deliveries.
    • Abortions IUD placement and other Gynecological Procedures.

References:

1. 1. Park et al., Clin Exp Reprod Med 2016;43(4):185-192
   2. Attilio Di SpiezioSardo et al., Chronic Endometritis, http://dx.doi.org/10.5772/63023.
   3. Michael Taylor; Leela Sharath Pillarisetty, In : StatPearls [Internet]. Treasure Island (FL): StatPearls, https://www.ncbi.nlm.nih.gov/books/NBK553124/
   4. Pic Credit by https://www.statpearls.com/physician/cme/activity/25430/?deg=DO

Dr Sarbani Mandal., MBBS (Hons.), MS (G&O), MRCOG 1. Senior Resident, Bhagajatin State General Hospital, Kolkata.