Chronic endometritis

Author: Thomas C. Michels
Date: July, 1995

Endometrial biopsy is performed to evaluate abnormal vaginal bleeding, to monitor noncontraceptive hormonal therapy, to evaluate infertility and to screen women at high risk for endometrial cancer. Outpatient endometrial biopsy is a relatively simple, low-risk procedure that is increasingly being performed by family physicians.(1)(2)(3)(4)(5)(6)

The results of an endometrial biopsy must be interpreted in light of the clinical setting in which the specimen is obtained.(6)(7)(8) Inflammation of the endometrium may be an incidental finding on such a biopsy. Endometrial inflammation can be categorized as acute, fibrotic or chronic.(9)

Acute endometritis is usually caused by an infectious process, such as pelvic inflammatory disease, but it may also occur in the immediate postpartum period. Endometrial biopsy is not generally indicated in acute infections or the postpartum state, although these conditions may lead to chronic endometritis.

Endometrial fibrosis (Asherman's syndrome) usually stems from scarring of the endometrium following too-vigorous curettage.

Chronic endometritis may be granulomatous or nongranulomatous (i.e., nonspecific).(10) It may be a finding on endometrial biopsy specimens obtained for surveillance or evaluation.

The literature does not contain clear guidelines for the management of chronic nonspecific endometritis. The explanation for this is that the relationship between symptoms and histopathology is not known, because chronic endometritis is usually an incidental finding on a biopsy done for reasons unrelated to the condition itself. In some cases, chronic endometritis may be a low-grade form of pelvic inflammatory disease; in others, infection does not seem to play a role.

Definition

Chronic endometritis is identified on the basis of its histopathology. It is a chronic inflammatory process of the endometrium manifested by a plasma cell infiltrate. While the diagnostic criteria for chronic endometritis remain controversial, most experts agree that an inflammatory infiltrate with at least some plasma cells must be present. In contrast, acute endometritis is characterized by an infiltrate composed predominantly of neutrophils.

Prevalence

Because the presence of chronic endometritis is determined on the basis of pathologic specimens obtained by endometrial biopsy, curettage or hysterectomy, the reported prevalence of this condition depends on the number of patients who seek care for problems that require these procedures.

The prevalence of chronic endometritis ranges from 0.8 percent to 19 percent in unselected series(11)(12)(13)(14)(15)(16)(17)(18)(19) and is as high as 72 percent in histologic specimens from women seeking care in a sexually transmitted disease clinic.(20) Despite this wide range, many series report similar prevalence figures for chronic endometritis. Data from these series indicate that chronic endometritis is detected in a mean of about 8 percent of endometrial specimens.(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)

Clinical Findings

Abnormal vaginal bleeding is the symptom most commonly reported by women with chronic endometritis. This bleeding can occur as intermenstrual bleeding, spotting, postocital bleeding or menorrhagia. Some form of irregular or heavy bleeding is reported by 80 to 90 percent of women with chronic endometritis in most series.(12)(13)(19)(22)(24)(25)(27) However, amenorrhea was reported in 21 percent of women in one study.(19)

The incidence of lower abdominal pain in women with chronic endometritis ranges from 36 percent to 89 percent, with a median of about 60 percent. Less common symptoms include fever, vaginal discharge and infertility.(12)(13)(15)

The most common physical finding in women with biopsy results showing chronic endometritis is uterine tenderness or cervical motion tenderness. The incidence of these findings ranges from 20 percent to 57 percent.(22)(27) Uterine or cervical tenderness occurs more frequently in certain groups, such as women with cervicitis or Chlamydia trachomatis infection. Occasionally, a patient with chronic endometritis is found to have an abdominal mass or an enlarged uterus. However, many women with chronic inflammation of the endometrium have a completely normal physical examination.

Laboratory tests should include a complete blood count, an erythrocyte sedimentation rate, a thyroid-stimulating hormone measurement (to evaluate abnormal vaginal bleeding) and a pregnancy test (in premenopausal women). Tests for C. trachomatis, Neisseria gonorrhoeae and Streptococcus agalactiae (group B Streptococcus) are indicated. All of these tests may have normal results, but the following abnormalities may be noted. Anemia may be present if blood loss has been substantial. Elevation of the leukocyte count and the erythrocyte sedimentation rate have been reported, especially in women with cervicitis.

Other laboratory tests generally are not useful, unless suggested by the history or the physical examination.

Pathology

The hallmark of chronic endometritis is plasma cell infiltration of the endometrium (Figure 1). This condition is also characterized by edema, hemorrhage and infiltration with neutrophils, eosinophils and lymphocytes. Occasional lymphoid follicles are seen in almost all cases. Rarely, a lymphoma-like lesion is present.

[ILLUSTRATION OMITTED]

In chronic endometritis, endometrial glands are usually proliferative, but the proliferation appears abnormal. Cellular crowding, irregular glands and changes resembling those of anovulatory cycles often occur. Cellular atypia are present in specimens with severe inflammation.(14)(17)(23)

Etiology

Chronic endometritis may be caused by a number of pathologic processes. Chlamydial infection and postpregnancy endometrial changes are clearly associated with chronic endometritis. The association between chronic endometritis and other conditions, such as leiomyomas of the uterus, is more speculative.

The classification of chronic endometritis is given in Table 1.(7)(9)(10) Although experimental studies show that changes consistent with chronic endometritis occur after bacterial infection of the endometrium, most studies attempting to isolate bacteria other than C. trachomatis in women with this condition have been unrewarding.

TABLE 1 Classification of Endometritis

Acute endometritisInfectiousBacterial (Neisseria gonorrhoeae, multiple agents) Viral (herpes simplex virus) Postpartum conditionFibrotic endometritisIntrauterine adhesions (Asherman's syndrome)Chronic endometritisNonspecific Infectious Chlamydia trachomatis Other agents, especially when associated with cervicitis or salpingitis Pregnancy-related Retained products of conception Recent pregnancy (term or aborted) Intrauterine foreign body Intrauterine device Submucosal leiomyoma of the uterus Radiation-related IdiopathicGranulomatous Infectious Tuberculosis Fungal infection (coccidioidomycosis) Parasitic infection (schistosomiasis, toxoplasmosis) Sarcoidosis Carcinoma of the uterus

Derived from references 7, 9 and 10.

Retained products of conception or a recent full-term or aborted pregnancy are common precursors of chronic endometritis. These pathologic changes can persist for many weeks after the end of the pregnancy.

Chronic endometritis is strongly associated with acute or chronic salpingitis. Studies of women with cervicitis and no clinical signs of salpingitis have revealed chronic endometritis on endometrial biopsy in a high proportion of cases.(11)(22)(27)(28) Some investigators have suggested that chronic endometritis, at least in this clinical setting, repesents an intermediate stage between cervicitis and salpingitis. In addition, chronic endometritis is strongly associated with C. trachomatis infection.(20)(22)(26)(29) Isolated reports suggest that other agents, such as Mycoplasma species, may also cause chronic endometritis.

An intrauterine foreign body may also be identified in association with chronic endometritis. This condition is particularly characteristic of the endometrial changes that occur with use of intrauterine devices (IUDs), especially those containing copper.(10)(25)(27)(30) The endometrial changes may occur because the tail of the IUD acts as a wick, allowing microbiologic colonization of the uterine cavity. Endometrial changes after a recent invasive procedure, such as dilatation and curettage (D&C), also fall into this group. Less common conditions associated with chronic nonspecific endometritis are submucosal tumors (benign or malignant) and radiation of the female genital tract.

Granulomatous endometritis is much less common than nonspecific endometritis, and it may be caused by a variety of infections. These include tuberculosis, sarcoidosis and fungal, parasitic or viral infection.

No cause is identified in up to one-third of women with chronic endometritis.(12),(19) Although it has been suggested that exogenous hormones, including oral contraceptives, play a role in chronic endometritis of idiopathic etiology, this association has not been substantiated in most studies.

Management

Whenever possible, the specific cause of chronic endometritis should be treated. Specific treatment is often possible in women with granulomatous endometritis, such as that caused by tuberculosis, and is sometimes possible in women with nongranulomatous endometritis, such as that caused by C. trachomatis. Frequently, however, clinical judgment must be used and therapy must be individualized.

Management options include observation, hormonal manipulation, antibiotic therapy, surgery (e.g., D&C, hysterectomy) or a combination of these approaches.

Some concern has been raised over the possibility that chronic endometritis may be an intermediate stage between mucopurulent cervicitis and salpingitis, and that women with endometritis alone may be at risk for tubal damage due to scarring.(10)(22)(27) Some authorities advocate the use of antibiotic therapy in patients with chronic endometritis. Most often, they recommend doxycycline (Vibramycin) in a dosage of 100 mg twice daily for 10 to 14 days. Doxycycline therapy is also recommended for women who have had a recent invasive procedure involving the uterus.

Women with postpartum or postabortion endometritis are usually managed surgically with a D&C, usually in combination with antibiotic therapy. Cyclic hormonal therapy with oral contraceptives or conjugated estrogens and progesterone may be tried first to effect a "chemical" D&C.

In light of these recommendations, the physician should first treat the patient based on any specific indicators, such as evidence of infection, a postpartum setting or a positive culture, smear or assay. It may be prudent to consider a course of antibiotics in patients with a negative culture or smear, especially those with an abnormal discharge, a history of pain or the finding of tenderness on physical examination. Otherwise, or if antibiotic therapy fails, it is logical to prescribe a three- to six-month cyclic course of hormonal therapy. Few patients should require a D&C, unless their condition represents a postpartum complication. Patients with symptoms that persist despite antibiotic therapy and three months of cyclic hormonal therapy should be referred to a gynecologist for further evaluation (Figure 2).

[ILLVSTRATION OMITTED]

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