Chronic endometritis in adults

What is chronic endometritis

Chronic endometritis is a chronic inflammation of the endometrium (the lining of the uterus). Chronic inflammation can interfere with the normal implantation of the embryo and its subsequent development. In addition, constant inflammation depletes the body, can provoke serious complications.

Identification of chronic endometritis is usually carried out by microscopic or histological examination. A sample of the endometrium is obtained either from a biopsy or during a hysteroscopy procedure. Under a microscope, a sample of the endometrium can be stained and analyzed for the presence of chronic inflammatory immune cells known as plasma cells. An endometrial specimen full of plasma cells is indicative of chronic endometritis. Cultures from the vagina or cervix are not a reliable indicator of chronic endometritis.

Before we can understand chronic inflammation and its important role in reproductive health, we must first understand what inflammation is. By its very nature, inflammation is the body’s attempt to protect itself from infections, irritants, and repair damaged cells. Inflammation is part of the body’s immune response.

In the beginning, inflammation is beneficial. For example, when your body is trying to fight off an infection caused by bacteria or viruses. However, sometimes inflammation can cause further tissue damage if it becomes chronic. It can be maintained even after the original cause has disappeared. In this situation, inflammation can be harmful.

Inflammation can be acute or chronic.

Acute inflammation. It starts suddenly, abruptly and quickly becomes severe. Signs and symptoms are present for only a few days, but in some cases they may last longer.

There are 5 main signs and symptoms of acute inflammation:

• pain – chemicals are released that stimulate nerve endings, which causes pain;
• redness – increased blood flow to the affected area causes redness;
• heat – increased blood flow to the affected area also leads to local warming;
• edema – it is caused by the leakage of fluid from local blood vessels;
• dysfunction.

Acute inflammation is usually easy to recognize and treat.

Chronic inflammation. Chronic inflammation means a long process that lasts for months or even years. This may be due to a failure to eliminate what was causing acute inflammation (persistent, poorly suppressed bacteria), a low-intensity chronic irritant that persists, or when the immune system attacks healthy tissues, mistaking them for harmful pathogens.

Chronic inflammation can be difficult to diagnose and effective treatment is not always available.

Inflammation is becoming a well-recognized contributing factor to reproductive dysfunction, including several common causes of infertility such as pelvic inflammatory disease, polycystic ovary syndrome, obesity, endometriosis, and recurrent pregnancy loss. Recently, chronic inflammation of the uterine mucosa has been of particular interest. This is called chronic endometritis.

Causes of chronic endometritis in adults

The lining of the uterus is responsible for developing the ability of the embryo to implant. The production of estrogen and progesterone by the ovaries causes changes in the uterine lining necessary for implantation. The changes that occur in the uterine mucosa are extremely complex and poorly understood. Some studies have identified chronic inflammation in women with failed implants. It is also believed that inflammation of the lining of the uterus can increase the risk of miscarriage.

There are several causes of endometritis and most of them are associated with an infection caused by pathogenic or opportunistic flora. The cervix, or the opening in a woman’s uterus that connects the uterine cavity to the vagina, is usually covered with mucus and prevents bacteria from migrating into the endometrial cavity. Catheters for intrauterine insemination or embryo transfer bypass the cervical pylorus and can cause infection. If the patient has a miscarriage, the cervix may dilate to allow the evacuation of the tissues of the deceased embryo, but bacterial infection by the ascending route is possible. Remnants of the placenta and membranes after pregnancy is also associated with infection.

In general, endometritis is caused by an infection. It could be chlamydia, gonorrhea, tuberculosis, or a mix of common vaginal bacteria. Inflammation is more likely to occur after a miscarriage or childbirth, but is also not uncommon after prolonged labor or caesarean section. The risk of developing endometritis is higher after pelvic surgery, which is performed through the cervix. These procedures include:

• dilatation and curettage during abortion;
• endometrial biopsy;
• hysteroscopy;
• installation of an intrauterine device (IUD);
• childbirth (more often after caesarean section than vaginal delivery).

Endometritis can occur at the same time as other pelvic infections.

Symptoms of chronic endometritis in adults

Outside of an exacerbation, there may be practically no symptoms. During periods of exacerbation, possible symptoms may include:

• bloating;
• abnormal vaginal bleeding or discharge;
• discomfort with bowel movements (including constipation);
• high fever;
• general discomfort, anxiety, or feeling unwell;
• pain in the lower abdomen or pelvis (pain in the uterus).

Treatment of chronic endometritis in adults

Treatment consists of removing the source of the infection (remnants of the placenta, fetal egg, hematomas, coils) followed by a short course of antibiotics. In some cases, a second “proof of cure” endometrial biopsy is performed after the course of antibiotics is completed to ensure a normal endometrium. Empiric antibiotic use is often used shortly before embryo transfer in IVF protocols to rule out any minimal endometritis at the time of implantation.

Diagnostics

There are some blood tests that are common non-specific markers of inflammation. One of the markers is called the erythrocyte sedimentation rate (also known as the ESR). ESR is not very useful in studying women of reproductive age, as it is affected by estrogen levels.

Another marker called C-reactive protein or CRP is independent of hormone levels, so it’s a much more reliable indicator of inflammation in women. A very high CRP level (>10) is usually an indicator of an acute infection. Moderately elevated levels may be a sign of low-grade chronic inflammation.

The lining of the uterus can be visualized directly by inserting a fiber optic telescope into the uterine cavity. This is called hysteroscopy. Sometimes this method can be used to diagnose chronic endometritis. For example, the presence of micropolyps is a reliable indicator of chronic endometritis.

Hysteroscopy can also be used to obtain a sample or biopsy of the lining of the uterus, which can be viewed under a microscope. In the lining of the uterus, one type of white blood cell that is a sign of chronic inflammation are “plasma” cells. Plasma cells can be seen by looking at a piece of uterine lining under a microscope. However, due to the presence of other similar-looking cells, it is not always easy to determine the presence of an abnormal number of plasma cells. Plasma cells have a marker on their surface called CD138. A sample of endometrial tissue can be stained to isolate CD138. This is a more reliable method for diagnosing chronic endometritis.

Modern treatments

If a specific cause of inflammation can be identified, treatment of the cause should result in resolution of the associated inflammation. For example, if a bacterial infection is found, antibiotic treatment can be tried. A recent study showed an increase in pregnancy and birth rates when women with mildly elevated CRP levels received low-dose aspirin before they became pregnant. However, no improvement was observed in obese women. In an animal study, it was also found that exposure to platelet rich plasma (PRP) suppresses the production of certain proteins produced in the lining of the uterus as a result of inflammation.

Does antibiotic treatment for chronic endometritis really work? A recent review of several studies looking at treating chronic endometritis with antibiotics found that women who had evidence of a cure (re-biopsy showed inflammation was obvious) were 6 times more likely to have an ongoing pregnancy or live birth compared to women with chronic endometritis which was not treated.

Prevention of chronic endometritis in adults at home

It is important to take care of your health by visiting a gynecologist every year. Endometritis can be caused by STIs (sexually transmitted infections). To prevent endometritis from STIs:

• treat STIs in a timely manner;
• make sure sexual partners are treated for STIs;
• Practice safe sex practices, such as using condoms.

Women who have had a caesarean section may be given antibiotics before the procedure to prevent infections.

Popular questions and answers

Answered questions about chronic endometritis gynecologist, PhD Mikhail Gavrilov.