Endometritis is an acute or chronic, usually bacterial infectious process affecting the endometrium.
Endometritis is defined as inflammation of the endometrium (i. e. the innermost layer of the uterine wall; Pic. 1), grouped in various typologies, based on its cause. It may present as acute or chronic and decreases the chances of in vitro fertilization (IVF) as well as spontaneous conception. Furthermore, endometritis can be responsible for obstetric complications.
The usual cause for endometritis is infection. In endometritis caused by infectious agens, the etiology is usually polymicrobial (i. e. several different bacterial species combined cause the illness). The most common organisms are Chlamydia trachomatis (chlamydia), Neisseria gonorrhoeae (gonorrhoea), Streptococcus agalactiae (Group B Streptococcus), Mycoplasma hominis, Mycobacterium tuberculosis, and various viruses. Most of those agens can cause pelvic inflammatory disease (PID).
Besides that, endometritis of chemical-mechanical origin can occur. This may be a result of irritation by intrauterine devices (IUD) or pessaries.
Acute form
The acute form usually has short duration and generally arises due to the persistence of placental (after childbirth) or abortive residues, or in combination with pelvic inflammatory disease (Pic. 2; Pic. 3), or with inflammatory conditions elsewhere in the urogenital tract (caused by bacteria or viruses).
Chronic form
Chronic inflammation may follow the acute stage (such a situation is seen more commonly), or it may occur more subtly, without passing through an acute phase. The origin of chronic inflammation can be microbiological or mechanical-chemical (as mentioned earlier). Though infectious etiology is more common, patients suffering from chronic endometritis may have an underlying cancer of the cervix or endometrium.
Diagnostics
Endometritis is diagnosed through a physical and pelvic exam, followed by several possible tests: taking samples from the cervix to search for the presence of bacteria, taking a sample of endometrium to asses under the microscope, collecting a sample of cervical discharge and observing it under the microscope, blood testing for markers of inflammation, or laparoscopy or hysteroscopy (using a camera to inspect an organ or an area visually, here inserted into the abdominal cavity or in the uterus).
Treatment
Endometritis is treated by antibiotics. If the patient’s condition is serious, a stay in a hospital with more complex treatment may be necessary.
Symptoms
Acute endometritis
The clinical presentation of acute endometritis is typically high fever and purulent, unpleasant-smelling vaginal discharge. Menstruation after acute endometritis is excessive.
Chronic endometritis
Chronic endometritis is often clinically silent. Possible symptoms comprise:
Associated diseases
Cervicitis
Cervicitis is an inflammation of cervix, the lower and narrow end of the uterus that opens into the vagina. Cervicitis may ascend and cause endometritis and pelvic inflammatory disease (PID). The condition is accompanied with changes in vaginal pH, for which reason it is more difficult for semen to swim into the uterus and later meet and possibly fertilize the egg.
Pelvic inflammatory disease (PID)
PID is inflammation of a woman’s reproductive organs including the uterus, fallopian tubes, ovaries, and cervix. It is usually induced by the migration of pathogenic microorganisms from the lower to upper genital tract. A history of pelvic inflammatory disease suggests the possibility of tubal damage, leading to disruption of sperm transport towards the egg. It is by far the major cause of ectopic pregnancies (e. g. a complication of pregnancy where the embryo attaches outside the uterus) and tubal factor infertility.
Complications
Pyometra
This term describes an accumulation of pus in the uterine cavity. In order for pyometra to develop, there must be both a bacterial infection and blockage of cervix through a stenosis (i. e. pathologic narrowing). Signs and symptoms include lower abdominal pain, rigors, fever, and discharge of pus on introduction of a sound into the uterus. Pyometra is treated with antibiotics.
Sepsis
Sepsis (whole body inflammation) is a life-threatening condition that arises when the immune system’s reaction to infection is escalated and causes injury to body’s own tissues and organs. Common symptoms include high fever, increased heart rate, increased breathing rate, and confusion. Sepsis may lead to septic shock, which Is a life-threatening emergency. Especially in the past, women after delivery were highly endangered by infection, possibly leading to sepsis and death. Such a condition is known under the term puerperal sepsis or puerperal fever.
Risk factors
Prevention
A very important way of preventing endometritis is high level of hygiene – during labor as well as other gynecological procedures, equipment and techniques should be sterile. Secondly, practicing safe sex and being routinely checked for or promptly diagnosed with a sexually transmitted infection helps reduce the risk of endometritis. When an STI occurs, finishing all prescribed treatment is important.
In some cases, endometritis can be associated with infertility. Though the exact mechanisms are yet to be fully understood, inflammation of the endometrium seems to interfere with oocyte fertilization and embryonic implantation. The relationship between chronic endometritis and infertility-related conditions has recently emerged as an area of inquiry.
Possible infertility-related conditions include for example repeated implantation failure (i. e. failure to conceive following two or three embryo transfer cycles or cumulative transfer of 10 good quality embryos), and recurrent miscarriage.
Untreated chronic endometritis thus seems to disrupt both spontaneous conception and IVF cycles (i. e. sequence of steps including in vitro fertilization, from monitoring and stimulating woman’s ovarian function to implantation of a fertilized egg to the patient’s uterus). Moreover, it can play a part in obstetric complications, such as intrauterine infections, preterm delivery, and postpartum endometritis.
Endometritis can cause scarring of the uterus, which prevents successful implantation and development of an embryo. This leads to increased risk of repeated miscarriages and implantation failure. However, prompt and proper treatment with antibiotics can significantly improve the odds.
