Endometritis is an inflammatory process in the inner mucous layer of the uterus – the endometrium. It can occur acutely or chronically, which leaves an imprint on the symptoms. Accompanied by pain, discharge, menstrual irregularities. Of paramount importance for the diagnosis of acute form are the data of gynecological examination and the results of vaginal smears; the chronic form of the disease is confirmed by ultrasound and hysteroscopy. Treatment includes antibacterial, anti-inflammatory therapy, physiorehabilitation.
N71 Inflammatory diseases of the uterus, except the cervix
Endometritis is often combined with inflammation of the muscular layer of the uterus – endomyometritis. The endometrium is the internal functional lining of the uterus, changing its structure throughout the menstrual cycle. Each cycle, it grows and matures anew, preparing for the attachment of a fertilized egg, and is rejected if pregnancy does not occur. Normally, the uterine cavity lined with endometrium is reliably protected from infection. But under certain conditions, infectious pathogens easily enter the uterus and cause an inflammatory reaction of its inner layer – endometritis. According to the nature of the course, acute and chronic forms are distinguished.
Disease can be caused by various pathogens: bacteria, viruses, fungi, parasites, mixed flora. Depending on the nature of origin , specific and nonspecific form are distinguished:
- Specific include infectious (viral, chlamydial, bacterial, protozoal, fungal) and parasitic endometritis. They can be caused by pathogens such as herpes simplex viruses, cytomegaloviruses, chlamydia, Mycobacterium tuberculosis, toxoplasma, mycoplasma, candida, radiant fungi, gonococci, etc.
- With the nonspecific nature of endometritis, the pathogenic flora in the uterus is not detected. The nonspecific form can be caused by bacterial vaginosis, HIV infection, the presence of an intrauterine device, taking hormonal contraceptives.
In the development of endometritis, the state of the immune, endocrine, and nervous systems is important, often aggravating the course of the disease. The onset of acute endometritis is often preceded by:
- abortion or mini-abortion,
- diagnostic curettage of the uterine cavity,
- hysteroscopy and other intrauterine manipulations.
Incomplete removal of the remains of the fetal egg, placenta, accumulation of liquid blood and clots favor the development of infection and acute inflammatory process of the inner surface of the uterus. The most common manifestation of postpartum infection is postpartum endometritis. It occurs in 4%-20% of cases after natural delivery and in 40% after cesarean section. This is due to hormonal and immune restructuring in the pregnant woman’s body, a decrease in overall immunity and resistance to infections.
The chronic form of endometritis is often a consequence of untreated acute endometritis that occurred after childbirth, abortion, intrauterine manipulations, due to the presence of foreign bodies of the uterus. In 80-90% of cases, chronic endometritis occurs among women of the reproductive period and tends to increase, which is explained by the widespread use of intrauterine contraception, an increase in the number of abortions, intrauterine diagnostic and therapeutic procedures. Chronic form is among the most common causes of infertility, miscarriages, failed attempts at in vitro fertilization, complicated pregnancies, childbirth and the postpartum period.
High-precision immunocytochemical diagnostics is used to detect an infectious agent in chronic endometritis. The chronic form of endometritis often has an erased clinical course without pronounced signs of microbial infection. There is a thickening of the uterine mucosa, serous plaque, hemorrhages, fibrous adhesions, leading to disruption of the normal functioning of the endometrium.
In the occurrence of endometritis, a special role is played by the reduction of barrier defense mechanisms that prevent the penetration of infection into the internal genitals. This may be caused by the following factors:
- Birth injuries of the mother. Ruptures of the perineum, vagina, cervix during childbirth contribute to the penetration of infection into the genital tract and its ascent into the uterine cavity.
- Mechanical, chemical, thermal factors that damage the mucous membrane of the vagina. Violation of hygiene of the genitals, frequent douching, the use of vaginal spermicidal agents, etc. lead to a change in the normal microflora of the vagina and its protective properties.
- Menstruation, childbirth, abortions. The release of blood leads to the leaching of the secret of the cervical canal, the alkalinization of the acidic environment of the vagina and a decrease in its bactericidal properties. Under these conditions, pathogenic microorganisms freely penetrate from the external environment and actively multiply on the wound surface of the uterus.
- Intrauterine contraceptives. For a long time, intrauterine spirals located in the uterine cavity become a potential source of inflammation, contributing to the penetration of infection by ascending the threads of the IUD. If endometritis occurs, then the removal of the IUD is necessary.
- Using vaginal tampons. Absorbing spotting, tampons are the optimal environment for the development of infection. Tampons should be changed every 4-6 hours, do not use them at night, before or after menstruation, in hot climates. Violation of the rules for using tampons can lead to the development of toxic shock syndrome.
- Common factors: chronic stress, overwork and insufficient hygiene. These factors weaken the body and make it at risk of infection.
Acute endometritis usually develops 3-4 days after infection and is manifested by fever, abdominal pain, discharge from the genital tract with an unpleasant odor, painful urination, increased pulse, chills. Acute endometritis is especially severe and rapid in patients with intrauterine spirals. Therefore, the first signs of acute endometritis are a reason for immediate consultation with a gynecologist.
During gynecological examination, a moderately enlarged and painful uterus, sucrovic or serous-purulent discharge is determined. The acute stage lasts from a week to ten days and with effective therapy ends with a cure, otherwise – a transition to chronic endometritis.
The severity of the course of chronic endometritis is due to the depth and duration of the existence of structural changes in the endometrium. The main manifestations of chronic endometritis are menstrual irregularities (poor or abundant menstruation), uterine bleeding, pathological serous-purulent or bloody discharge, aching pains in the lower abdomen, painful sexual intercourse. A two-handed gynecological examination reveals a slight compaction and an increase in the size of the uterus.
Structural changes in the endometrium in chronic endometritis can cause the formation and proliferation of polyps and cysts. Chronic endometritis is the cause of infertility in 10% of cases, and miscarriage in 60% of cases. The inflammatory process often involves the muscular layer of the uterus – myoendometritis occurs.
The endometrium is an important functional layer of the uterus responsible for ensuring the normal course of pregnancy. Inflammatory diseases of the endometrium – endometritis – entail a complicated course of pregnancy: the threat of miscarriage, placental insufficiency, postpartum bleeding. Therefore, the management of pregnancy in a woman with endometritis should be carried out with increased attention.
The long-term consequences of endometritis are adhesions inside the uterus (intrauterine synechiae), sclerosis of the uterine cavity, impaired menstrual cycle, polyps and endometrial cysts. With endometritis, the ovaries and tubes may be involved in the inflammatory process, peritonitis, adhesions of the intestine and pelvic organs (adhesive disease) may develop. Adhesive disease is manifested by pain and often leads to infertility.
Diagnosis of acute endometritis is based on the collection of anamnesis of the disease, patient complaints, symptoms, gynecological examination, clinical blood test and bacterioscopic examination of smears. Women with acute endometritis are treated inpatient, because there is a potential risk of developing severe septic complications (parametritis, pelvioperitonitis, peritonitis).
In the diagnosis of the chronic form of endometritis, in addition to clarifying the clinical symptoms and anamnesis of the disease, a special role belongs to the curettage of the uterine mucosa carried out for diagnostic purposes. Histological examination of the altered endometrium allows to confirm the diagnosis of chronic endometritis. Ultrasound (ultrasound) and endoscopic (hysteroscopy) studies are important diagnostic methods that allow detecting structural changes in the endometrium.
Therapy of acute endometritis
In the acute phase of endometritis, patients are treated in a hospital in compliance with bed rest, mental and physical rest, an easily digestible full-fledged diet, and a drinking regime. The basis of the drug treatment of acute endometritis is:
- Antibacterial therapy. It is selected taking into account the sensitivity of the pathogen (amoxicillin, ampicillin, clindamycin, gentamicin, kanamycin, lincomycin, etc.). With mixed microbial flora, a combination of several antibiotics is indicated. Due to the frequent addition of anaerobic pathogens, metronidazole is included in the treatment regimen for acute endometritis.
- Pathogenetic therapy. In order to relieve intoxication, intravenous administration of salt and protein solutions up to 2-2.5 liters per day is indicated. It is advisable to include multivitamins, antihistamines, immunomodulators, probiotics, antifungal agents in the treatment regimen for acute endometritis.
- Treatment with physical factors. For analgesic, anti–inflammatory and hemostatic purposes, cold is applied to the abdominal area (2 hours – cold, 30 minutes – break). When acute symptoms subside, physiotherapy, hirudotherapy (medical leeches) are prescribed.
Therapy of chronic endometritis
In the treatment of chronic endometritis, modern gynecology applies an integrated approach, including antimicrobial, immunomodulatory, restorative, physiotherapeutic treatment. Treatment is carried out in stages. The first step is the elimination of infectious agents, followed by a course aimed at restoring the endometrium. Broad-spectrum antibiotics (sparfloxacin, doxycycline, etc.) are usually used. The recovery course is based on a combination of hormonal (estradiol plus progesterone) and metabolic therapy (calf blood hemoderivate, inosine, ascorbic acid, vitamin E).
Medications can be injected directly into the uterine mucosa, which creates an increased concentration of them directly in the focus of inflammation and provides a high therapeutic effect. Uterine bleeding is stopped by the appointment of hormones or an aminocaproic acid solution (intravenously or intrauterine).
An important place in the treatment of chronic endometritis is given to physiotherapy: UHF, electrophoresis of copper, zinc, lidase, iodine, pulsed ultrasound therapy, magnetotherapy. Physiotherapeutic treatment reduces inflammatory edema of the endometrium, activates blood circulation, stimulates immunological reactions. Patients with chronic endometritis are shown spa therapy (mud therapy, hydrotherapy).
The effectiveness of treatment of chronic endometritis is evaluated according to the following criteria:
- restoration of the morphological structure of the endometrium (based on ultrasound results)
- restoration of the menstrual cycle.
- elimination of infection
- disappearance of pathological symptoms (pain, bleeding)
- restoration of childbearing function
To avoid the occurrence of endometritis, it is necessary to prevent abortions, observe hygiene measures, especially during the menstrual period, prevent postpartum and post-abortion infections, use barrier contraception (condoms) to prevent sexually transmitted infections. Timely detection of asymptomatic infections and their treatment in most cases gives a favorable prognosis for subsequent pregnancies and childbirth.