{"paper_id":"0aaaa5b9-2d5b-4e30-88ad-520b40e11303","body_text":"~ 354 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2020; 4(6): 354-359 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2020; 4(6): 354-359 \nReceived: 22-09-2020 \nAccepted: 26-10-2020 \n \nDr. Uma Jain  \nDesignated Professor, Department \nof Obstetrics and Gynecology,  \nGMC Associated with Hospital, \nShivpuri, Madhya Pradesh, India \n \nDr. Dilip Jain \nConsultant Pathologist, Arihant \nPathology Lab, Shivpuri, Madhya \nPradesh, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr. Uma Jain  \nDesignated Professor, Department \nof Obstetrics and Gynecology,  \nGMC Associated with Hospital, \nShivpuri, Madhya Pradesh, India \n \nChronic endometritis: “Clinical presentation and \nattributing specific etiological factor” \n \nDr. Uma Jain and Dr. Dilip Jain \n \nDOI: https://doi.org/10.33545/gynae.2020.v4.i6f.778 \n \nAbstract \nIntroduction: Endometritis is the inflammation of the endometrial lining of the uterus. In addition to the \nendometrium, inflammation may involve the myometrium and occasionally, the parametrium. \nAim of the study: the study aimed to find \n1. The correlation of endometritis with  various clinical characteristics of the patients e.g. pelvic pain, \ndysfunctional uterine bleeding, dyspareunia, vaginal discharge, infertility, recurrent miscarriage and \namenorrhea. \n2. To determine the various attributing etiological factors and history e.g.  its relation with PID, IUD, \nPostpartum factor, Post abortal factors, postmenopausal, tubercular and idiopathic cause. \nMaterial and Method: A retrospective study was done of chronic endometritis reports and cases that were \ndiagnosed as chronic endometritis after aspiration biopsy using pipelle procedure. The duration of the study \nwas from January 2016 to September 2020 at a private clinic and a pathology centre of Shivpuri. Out of \ncases, 353 cases 34 histopathological reports of chronic endometritis were reviewed to identify the cause of \nendometritis and its association with clinical findings and any significant history.  \nResults: In our study Out of 353 cases 34 cases found to be reported as endometritis. A total of 34 cases \nwere studied. The prevalence of endometritis was 9.6%. The age of women ranges from 20 to 70 years. A \nmaximum number of patients was between 25 -35 years. Most of the patients were rural (79.41%), most of \nthem were married (97.06%) and (47.06%) cased were multiparous.  \nThe most common pre senting complain was (35.29%) abnormal uterine bleeding followed by  (17.65%) \nabnormal vaginal discharge, lower abdominal pain (14.71%)  and infertility (14.71 %). Recurrent \nmiscarriage 8.82%, Dysmenorrhoea 2.94%, Dysparaaunia 2.94% and Amenorroea 2.94%.  \nThe most common finding on trans abdominal and Trans -vaginal ultrasound scan was thickened and \nheterogeneous endometrium, asynchronous with the phase of the menstrual cycle (47.05%).  \nIn 58.82% cases, no significant past history was there, in 14.71% cases th e history of instrumentation was \nthere and in 8.82% cases history of IUD insertion was there. 5.88% cases posted abortal, 2.94% were \npostpartum, 2.94% were postmenopausal with cervical stenosis and with hematometra and 5.88% were \nTubercular. \nConclusion: Chronic endometritis though asymptomatic is associated with infertility and poor reproductive \noutcome, Diagnosis is usually done by hysteroscopy, histopathology, and microbial examination. \n \nKeywords: chronic nonspecific endometritis, aspiration biopsy, abnormal uterine bleeding \n \n1. Introduction  \nThe endometrium is the internal lining of the womb (uterus), where the embryo implants and \ngrows during pregnancy.  Endometritis is the inflammation of the endometrial lining of the \nuterus. In addition to the endometri um, inflammation may involve the myometrium and \noccasionally, the parametrium.  The exfoliation of the endometrium provides a natural \nscavenging effect which prevents endometrial infection from becoming established. Chronic \nendometritis, characterized by an  infiltrate of lymphocytes and plasma cells (often with an \nadditional minor component of eosinophils)  [1] may follow pregnancy or abortion. Be the result \nof an intrauterine device (IUD), be associated with a submucosal leiomyoma, or be accompanied \nby mucop urulent cervicitis and/or pelvic inflammatory disease (PID)  [2, 3]. Patients suffering \nfrom chronic endometritis may have an underlying cancer of cervix or endometrium. Pyometra \nis usually met within elderly women and is one of the best -recognized forms of  chronic \nendometritis. The clinical term, senile endometritis, suggested a chronic infection of the \nendometrium, usually low -grade [4]. CE is often asymptomatic or present with non – specific \nclinical symptoms, such as pelvic pain, dysfunctional uterine bleeding, dyspareunia, vaginal  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 355 ~ \ndischarge, vaginitis, recurrent cystitis and mild gastrointestinal \ndiscomfort [5]. Current evidence suggested that chronic \nendometritis is associated with infertility and poor reproductive \noutcome [6]. Chronic endometritis c an affect up to a third of \ninfertile women. However, it can be the cause of repeated \nimplantation failure or recurrent pregnancy loss in many cases. \nChronic deciduitis was reported to be linked to preterm labor \n(41%) [7, 8 ]. Chronic endometritis is often c linically silent. \nTherefore, it is impossible to accurately determine its true \nprevalence in the general population  [9]. The prevalence of CE \nranges from 8% to 72% in women of reproductive age [10]. \nThe most frequent causative agents for chronic endometrit is are \nInfectious agents:  Gonorrhea, Chlamydia, Mycoplasma, \nUreaplasma, Escherichia Coli, Streptococcus spp., \nStaphylococcus spp, Enterococcus faecalis, Yeast, and \nTuberculosis [11]. Specific infections agents causing endometritis \ninclude herpesvirus, whic h may be associated with neonatal \ninfections [12] cytomegalovirus [13] which can also be an \nassociated with parental infections as well as spontaneous \nabortions; toxoplasma  [14] which can also be responsible for \nspontaneous abortion; mycoplasma organisms  [15] which are \nsuggested as a cause of infertility; and actinomycetes  [16, 17] \nfrequently seen in women using intrauterine contraceptive \ndevices. For diagnosis of chronic endometritis - in blood Test \nelevations in the peripheral white blood count and erythro cyte \nsedimentation rate can be seen. \nHistopathological diagnosis using H & E (Hematoxylin & \nEosin) staining  is the gold standard for the diagnosis but it is \ntime-consuming and low diagnostic rate <10%  [18, 19]. The \nPresence of 1 -5 plasma cells/HPF of discr ete clusters of plasma \ncells is generally accepted as the histological diagnostic criterion \nfor chronic endometritis.  \nTB endometritis is often focal. The demonstration of a typical \ncaseous granuloma with giant epithelioid cells is suggestive of \nTB. Histopathological screening of patients by dilation and \ncurettage, though most accurate, is expensive, time -consuming \nand involves hospitalization with complications of surgery and \nhazards. An endometrial aspiration biopsy can be a useful \nalternative to DNC. Asp iration cytology is better than \nconventional D&C because in this procedure no cervical dilation \nis required, it is cost -effective, it provides adequate tissue \nsamples, it can be done in an office setting, no anaesthesia is \nrequired and diagnostic accuracy is 90-98%. Variety of devices \ncan be used for endometrial biopsy aspiration like Novak curette \nVABRA curette Pipelle Device or gynosampler. The \nhistopathological diagnosis is usually available in 3-4 days. \nTB endometritis is often focal, and pathological c hanges such as \nulceration, caseous nacreous and tuberculosis. \nHPE of the specimens shows typical features of TB infection in \nthe form of granulomatous caseous lesions. The demonstration \nof a typical caseous granuloma with giant epithelioid cells is \nsuggestive of TB. \n \nImmunohistochemistry (IHC) with CD138 (syndecan – 1): \nThis method has higher sensitivity of 56% as compared to 13% \nfor H&E staining [19], it is more accurate [20]. \nIt reduces the false -negative diagnosis [19] but this method is not \nyet recommended in daily practice and not widely used for the \ndiagnosis of chronic endometritis. \n \nMicrobiological culture: Microbial culture (growing bacteria in \nthe lab) is the conventional method for identification of bacteria \nand infection. However, it has been shown that between 20-60% \nof bacteria cannot be cultured in the laboratory. \nMicrobial culture, the most reliable of the three classic methods, \nhas few limitations like contamination of the microbial culture \nwith skin or environmental bacteria: Usually remains Po sitive in \n75% of histologically confirmed CE Commonly cultured \nbacteria are Streptococcus agalactiae: 77.5%, Mycoplasma / \nUreaplasma: 25%, Chlamydia: 13% [11]. \n \nUltrasound: TVS is better than abdominal Ultrasound.  Indirect \nsonography signs are - increase in  endometrial thickness, \nasynchronous with the phase of the menstrual cycle, Persistently \nthin endometrium (Tuberculosis), Irregularity of the \nendometrium, Endometrium with hyperechogenic spots \nIntracavitary synechiae, Micropolyps, Fluid or debris \naccumulated within the endometrial cavity. Hematometra, \nHypervascular endometrium in the secretory face, Sometimes \nCalcification of entire endometrium can be seen [21, 22]. \n \nHysteroscopic diagnosis: Hysteroscopy is a useful diagnostic \nProcedure to detect endometriti s. It is usually done in the \nfollicular phase of the menstrual cycle Hysteroscopy is usually \ndone in the follicular phase (between D6 and 12) of the \nmenstrual cycle. Mucosal edema, Focal or  diffuse endometrial \nhyperemia or Micro Polyps can be seen  [23]. Office Hysteroscopy \nis having sensitivity 40%, specificity 80% (Bouet et al., 2016), \nAccuracy of hysteroscopy was observed in 93.4% [24]. \n \nMolecular Diagnosis: Reverse- Reverse transcription -\npolymerase chain reaction (RT -PCR) test can be used for the \nmolecular diagnosis of chronic endometritis. \nNAAT- The nucleic -acid amplification tests (NAAT) provide \nresults in a few hours. PCR is a rapid molecular method.  \nNowadays various tests are available to assess the health of the \nendometrium. CRGH offers a comprehensive assessment of the \nendometrium [25]. The quarter includes. \nERA (endometrial Receptivity Assay) \nEMMA (Endometrial Microbiome Metagenomic Analysis) \nALICE (Analysis of infectious chronic Endometritis) \nNKT (Natural Killer Test) (please refer to the section o n natural \nkiller cell test and immunotherapy \nThese tests are very useful in cases of recurrent implantation \nfailure.  \n \nTreatment: Generally, the drug of choice is doxycycline, \nadministered in doses of 100 mg every 12 hours for 14 days. \nAlternatively, the ad ministration of cephalosporins, macrolides, \nor quinolones is possible. Partner is advised to undergo the same \nantibiotic treatment. If endometritis persists then endometrial \nculture should be considered and appropriate antibiotic treatment \nshould be given.  Women with cured endometritis showed a \nhigher pregnancy rate and live birth rate in comparison with \nwomen with chronic endometritis [26]. \nIn the presence of confirmed tuberculous (isoniazid, ethambutol, \nrifampicin, and pyrazin amide for 2 months, followed by \nisoniazid and rifampicin for another 4 months) should be given.  \n \nAim of the study \nThe study aimed to find \n1. The correlation of endometritis with various clinical \ncharacteristics of the patients e.g. pelvic pain, dysfunctional \nuterine bleeding, dyspareuni a, vaginal discharge, infertility, \nrecurrent miscarriage and amenorrhea. \n2. To determine the various attributing etiological factors and \nhistory e.g. its relation with PID, IUD, Postpartum factor, \nPost abortal factors, postmenopausal, tubercular and \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 356 ~ \nidiopathic cause. \n \n2. Material and method  \nThe Inclusion Criteria  for the study were those women \npresenting with complaints of: Abnormal uterine bleeding, \nabnormal vaginal discharge, Lower Abdominal pain, \nDysmenorrhoea, Dysparaaunia, Unable to conceive (Infertility ), \nRecurrent miscarriage, Amenorrhea and backache. \n \nThe exclusion criteria were \nA. Pregnant women  \nB. History and signs were suggestive of acute pelvic infection.  \nA retrospective study was done of the reports of Diagnosed \ncases of chronic endometritis (Endometrial samples were \nobtained by an office procedure in which aspiration by piipelle \nforceps was done on the Outdoor examination table (without \nneed for cervical dilatation and anaesthesia and sent for the \nhistopathological examination (HPE)). The duration of the study \nwas from January 2016 to September 2020 at a private clinic and \na pathology centre of Shivpuri district. Total 360 reports of \nendometrial aspiration were there, 7 reports were labelled as less \nthan optimal. So Out of 353 cases, 34 cases rep orted as \nendometritis 34 histopathological reports were reviewed to \nidentify the cause of endometritis and its association with \nclinical findings. Complete clinical history, age, residence, \nparity, literacy, marital status, presenting symptoms and clinical  \nevaluation, ultrasound findings and all histopathological reports \nof endometrial samples were analyzed. \nData were coded and entered into Microsoft Excel worksheet. \nAll the data was analyzed using IBM SPSS ver.  20 software. \nFrequency distribution and cross  tabulation was used to prepare \ntables, data is expressed as percentage. \n \n3. Result  \n1. Adequacy of Histopathological Samples  \nAdequacy of a sample obtained was reported by histopathologist \nbased on the amount of sample obtained as (a) unsatisfactory, \n(b) less than optimal (c) satisfactory. \n \n \n \nGraph 1: shows that out of 360 samples, 353 samples (98.05%) were satisfactory, seven cases (1.94%)  \nwere less than optimal, and no case was reported as unsatisfactory.\n2. Prevalence of endometritis  \n \n \n \nFig 1: Prevalence of Chronic Endometritis- in our study Out of 353 cases 34 cases reported as  \nendometritis the prevalence of endometritis was 9.6%. \n \n \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 357 ~ \n3. Socio-demographic characteristics \n \nTable 1: Socio-demographic characteristics A total of 34 cases were studied. The age of women ranges from 20 to 70 years. The maximum number \nof patients was between 25-35 years. Most of the patients were rural (79.41%), most of them were married (97.06%) and (47.06%) cases were \nmultiparous \n \nAge Group (years) No. of cases Total (%) \n<25 1 2.94% \n25-34 16 47.06% \n35-44 9 26.47% \n45-54 5 14.71% \n>55 3 8.82% \nResidence   \nRural 27 79.41% \nUrban 7 20.59% \nMarital Status   \nMarried 33 97.06% \nUnmarried 1 2.94% \nParity   \nNulliparous 6 17.65% \nPrimiparous 12 35.29% \nMultiparous 16 47.06% \n \n4. Principal presenting symptoms \n \nTable 2: Principal presenting symptoms in 34 cases the most common \npresenting complaint was (35.29%) abnormal uterine bleeding followed \nby (17.65%) abnormal vaginal discharge, lower abdominal pain \n(14.71%) and infertility (14.71 %) \n \nPresenting symptom No. of \ncases \nPercentage \nof cases \nAbnormal uterine \nbleeding \nIntermenstrual Bleeding \n12 35.29% Menorrhagia \nMenometrorrhagia \nLower Abdominal pain 5 14.71% \nAmenorrhoea 1 2.94% \nAbnormal Vaginal discharge 6 17.65% \nDysmenorrhoea 1 2.94% \nDyspareunia 1 2.94% \nUnable to conceive (Infertility) 5 14.71% \nRecurrent miscarriage 3 8.82% \nTotal 34 100 \n \n \n5. Endometrial Findings on trans abdominal and Trans -\nvaginal ultrasound scan \n \nTable 3: Endometrial Findings on trans abdominal and Trans-vaginal \nultrasound scan- The most common finding on trans abdominal and \nTrans-vaginal ultrasound scan was Thickened and Heterogeneous \nendometrium, asynchronous with the phase of the menstrual cycle \n(47.05%) \n \nFinding on Ultrasound No. Percentage \nNormal Endometrium 9 26.47% \nFluid or debris accumulated within the endometrial 3 8.82% \nPersistently thin endometrium 3 8.82% \nThickened and Heterogeneous endometrium, \nasynchronous with the phase of the menstrual cycle. 16 47.05% \nEndometrium with hyperechogenic spots (Intracavitary \nsynechiae) 2 5.88% \nSometimes Calcification of entire endometrium 1 2.94% \nTotal 34 100 \n \n \n6. Histopathological finding and attributing specific Etiological factors  \n \nTable 4: Histopathological finding and Associated past history -The most common histopathological finding was chronic nonspecific endometritis. \nIn 58.82% cases, no significant past history was there, in 14.71% cases the history of instrumentation was there and in 8.82% cases history of IUD \ninsertion was there. 5.88% cases were postabortal, 2.94% were postpartum, 2.94% were postmenopausal with cervical stenosis and with \nhematometra and 5.88% were Tubercular \n \nHistopathological finding Significant history Number Percentage \nChronic nonspecific endometritis \nNo significant history only clinical finding 20 58.82% \nhistory of instrumentation 5 14.71% \nhistory of IUD insertion 3 8.82% \nPost abortal 2 5.88% \n Postpartum 1 2.94% \n Post menopausal (Cervical stenosis with hematometra) 1 2.94% \nTubercular endometritis (Past History of Tuberculosis, History & clinical symptoms suggestive of Tuberculosis) 2 5.88% \nTotal 34 100 \n \n4. Discussion \nDiagnosis of CE represents a challenge for the gynaecologist. \nThe clinical manifestatio ns of CE such as pelvic pain, vaginal \ndischarge, dyspareunia and abnormal vaginal bleeding are non – \nspecific, while about 25% of patients with CE are asymptomatic  \n[27]. \nA total of 34 cases were studied. The age of women ranges from \n20 to 70 years. \nIn our study, the chronic endometritis was most common in 25 -\n35 years of age which was not consistent with one another study \nin which chronic endometritis was most common, 41.1% in 41 -\n50 years of age [28]. \nIn our study, most of the patient was multiparous (47.06% ) \nwhich was not consistent with one another study in which 80.5% \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 358 ~ \nmultiparous 9.2% primiparous, and 10.3% nulliparous [28]. \nIn our study chronic endometritis was found in 9.4% cases \nwhich were lower than the study of Adegboyega PA et al. Who \nreported 15.6% prevalence of endometritis  [1]. And the \nprevalence rate of chronic endometritis was consistent with \nanother study in which the prevalence rate of CE to be \napproximately 10% to 11% based on biopsies of patients who \nunderwent hysterectomies due to benign gynecologic conditions [29]. \nIn our study, the most common presenting complaint was \nabnormal uterine bleeding (35.29%). Followed by (17.65%) \nabnormal vaginal discharge, lower abdominal pain (14.71%) and \nin our study infertility was in (14.71 %) and Recurrent \nmiscarriage was in 8.82% cases. \nThe most common symptoms were menstrual disturbances, \npresent in virtually every patient and pelvic pain or tenderness, \nfound in 50% of the women.  \nThe abnormal vaginal bleeding was observed in a higher number \nof patients th an another study in which Chronic endometritis is \nobserved in 3 -10% of women who undergo endometrial biopsy \nfor abnormal uterine bleeding (AUB)  [30] and our study was \nconsistent with one another study in which abnormal vaginal \nbleeding was the most common presenting symptom [28].  \nIn Study of “Dana” overall prevalence rate of chronic \nendometritis was 9% The prevalence in (REPL) recurrent early \npregnancy loss was 7% in FD (fetal death) group was 40% and \nin combined (REPL) /FD group was 11% The cure rate was \n100% after a course of antibiotic.  \nIn the study of Fuminori Kimura  [31] prevalence of chronic \nendometritis was found to be 2.8 -56.8% infertile women, 14% - \n67.5% in women recurrent implantation failure and 9.3% - \n67.6% in women with recurrent pregnancy lo ss and found \nantibiotic administration is an effective therapeutic option. The \nprevalence of chronic endometritis in infertility 2.8% and 24.3% \nby different authors [32].  \nThe prevalence of chronic endometritis in RPL (Recurrent \npregnancy loss) was reporte d 43.0%, 52.0%, 8.9% by different \nauthors [33]. \nAccording to a recent prospective study of patients with RIF of \nRPL, the CE prevalence rate in the RIF group was 14% (Six of \n43) and 27% in the RPL group (14 of 51)  [34] in our study there \nwas no data of RIF (recurrent implantation failure). \nThe most common finding on Trans  abdominal and Trans -\nvaginal ultrasound scan was Thickened and Heterogeneous \nendometrium, asynchronous with the phase of the menstrual \ncycle (47.05%) which was consistent with one another study. \nThe most common histopathological finding was chronic \nnonspecific endometritis.  \nIn 58.82% cases, no significant past history was there, history of \nIUD insertion in 8.82% cases which was consistent with one \nanother study in which IUD insertion history  was found in 11% \ncases [31].  \nIn our study 14.71% cases the history of instrumentation was \nthere, in 8.82% cases history of IUD insertion was there. 5.88% \ncases were postabortal, 2.94% were postpartum, 2.94% were \npostmenopausal with Cervical stenosis and with hematometra \nand 5.88% were Tubercular. \nIn one another study Chronic endometritis could be attributed to \na specific etiologic factor in 84% of the patients: pelvic \ninflammatory disease in 25%, intrauterine contraceptive device \nin 14%, postpartum factor s in 12% and postabortal factors in \n41% [35]. \nIn a large 1978 review, 53 per cent of the cases of chronic non -\ngranulomatous endometritis were considered to be post -\ninfectious in origin (postpartum, postabortal, or associated with \nintrauterine contraceptive  devices or pelvic inflammatory \ndisease, 26 per cent were the result of stagnation, 4.5 per cent \nwere associated with carcinoma in situ of the cervix, and 16.5 \nper cent were idiopathic, although there was a high rate of oral \ncontraceptive usage among these idiopathic cases [1]. \n \n5. Conclusion \nChronic endometritis is a low -grade infection of the \nendometrium. Most of the women remain asymptomatic. \nVarious risk factors like childbirth, miscarriage, caesarian \ndelivery, STDs; Pelvic procedures like D&C, Endometr ial \nbiopsy, hysteroscopy, and IUD insertion are the reason for the \nuterus lining to be inflamed. \nUntreated Chronic endometritis has been linked with fertility \nissues, including an inability to conceive, recurrent implantation \nfailure (RIF) and spontaneous abortion and poor reproductive \noutcome. Antibiotic treatment improves implantation rates and \ndecreases the rate of abortion and the poor reproductive outcome \nso it is must to think about endometritis in such type of patient \nand to treat it timely.  \n \n6. References \n1. Adegboyega PA, Adegboyega PA, Pei Y, McLarty J. \nRelationship between eosinophils and  chronic endometritis. \nHum Pathol 2010;41:33-7. \n2. Rotterdam H . Chronic endometritis. A clini copathologic \nstudy. 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