What is Endometritis?

Endometritis is a condition where the inner lining of the uterus, called the endometrium, gets inflamed. This very often happens due to an infection. When this infection spreads to the fallopian tubes, ovaries, or the lining of the pelvis, it becomes what we call pelvic inflammatory disease (PID). There are generally two kinds of endometritis: acute and chronic. A specific type of acute endometritis is postpartum endometritis, which occurs after pregnancy.

When acute endometritis happens without a connection to pregnancy, that means there’s an infection in the endometrium that has been there for 30 days or less. This kind of infection often occurs due to a sexually transmitted infection or bacterial vaginosis (BV), which is a condition where bad bacteria outnumber the good ones in the vagina. Common symptoms appear similar to PID, such as fever, pain in the pelvis and abnormal vaginal discharge, and can range from mild to severe. Because these symptoms also occur in PID, some doctors might see acute endometritis as the same as PID. In these cases, tiny abscesses, or pockets of pus, form, and white blood cells flood into the endometrium, which is what we can observe via a microscope. Interestingly, while acute salpingitis, which often happens alongside acute endometritis inside PID, can cause infertility due to scarring, acute endometritis, on its own, doesn’t lessen the chances of having a baby.

Chronic endometritis, on the other hand, is a mild inflammation of the endometrium that usually happens due to bacterial colonization not connected to pregnancy and lasts for 30 days or more. It shows plasma cells in the endometrial stroma, which means cells are in the connective tissue of the endometrium, and other signs of ongoing inflammation. People with chronic endometritis often don’t have symptoms; but when they do, they might experience abnormal bleeding from the uterus, pain during intercourse, and pain in the pelvis. Chronic endometritis is often linked to repeated pregnancy loss and infertility. It can be hard to diagnose because, unlike acute endometritis, there is no defined set of diagnostic criteria. However, the presence of endometrial stromal plasmacytes is often a key finding.

Postpartum endometritis, which occurs after pregnancy, is the most frequent cause of infection after childbirth. In most cases, postpartum endometritis is polymicrobial, which means it involves both types of bacteria that need or don’t need oxygen to live. It often happens due to the natural bacteria from the vagina moving into the uterine cavity when a woman is in labor and giving birth. Women who have a cesarean delivery are 5 to 20 times more likely to get endometritis than those who deliver vaginally.

What Causes Endometritis?

Endometritis is a condition where the lining of your uterus becomes infected. This usually happens when germs travel from the lower parts of your reproductive system, like the cervix and vagina, up into the uterus. Identifying the exact germs causing the infection can sometimes be difficult, and it can differ depending on the type of endometritis you have.

Acute Endometritis

Acute endometritis typically results from sexually transmitted infections (STIs). Over 85% of acute endometritis cases are caused by STIs. The most common germs causing this kind of endometritis are Chlamydia trachomatis, followed by Neisseria gonorrhoeae, both of which are types of STIs.

If you are younger than 25, have a history of STIs, engage in high-risk sexual behavior like having multiple partners, or have undergone gynecological procedures like getting intrauterine devices or endometrial biopsies, you are more likely to get acute endometritis.

Chronic Endometritis

Chronic endometritis is a long-lasting inflammation of the uterus, but the exact cause is often unknown. It can sometimes be linked to noninfectious causes like intrauterine contraceptive devices, endometrial polyps, and submucosal leiomyomas. However, when germs do cause it, they are often a mix of organisms commonly found in the vaginal vault, like Streptococcus species, Enterococcus faecalis, Escherichia coli, among others.

Risk factors for chronic endometritis include the use of intrauterine contraceptive devices, having given birth multiple times, a history of abortions, or experiencing unusual uterine bleeding.

Postpartum Endometritis

Postpartum endometritis is an infection of the uterus following childbirth. During pregnancy, the amniotic membrane shields the uterus from infection, but as the cervix widens and the membranes rupturing during childbirth, there is an increased chance of germs entering the uterus.

This chance increases if foreign bodies like cervical exam tools or monitoring devices are inserted into the uterus. Dead or damaged uterine tissue can also attract more bacteria. This type of endometritis can be caused by a variety of germs, both aerobic and anaerobic, including Streptococci, Staphylococcus, Enterococcus, Escherichia coli, and others.

Chlamydia trachomatis can also cause postpartum endometritis, though it is usually seen in instances where symptoms appear later on. Severe infections with germs like Streptococcus pyogenes, Staphylococcus aureus, or Clostridium can lead to serious health conditions.

Risk factors for postpartum endometritis include having a cesarean delivery, infection of the amniotic fluid during labor, having your water break for a long time before delivery, multiple cervical exams, manual removal of the placenta, delivery assisted by tools, and health conditions like HIV, diabetes, and obesity. Understanding these risk factors can help recognize and manage postpartum endometritis early.

Risk Factors and Frequency for Endometritis

Acute endometritis often occurs alongside PID (Pelvic Inflammatory Disease) which is fairly common with 8% incidence in the United States and 32% in developing countries. In the US, around 50% of PID cases are linked with Chlamydia trachomatis and Neisseria gonorrhoeae infections.

Chronic endometritis has mild symptoms making it difficult to estimate its true prevalence. However, among those suffering recurrent pregnancy loss, the incidence could be as high as 30%.

Postpartum endometritis, an infection that happens after a woman has given birth, is the top cause of fever in new mothers.
Its occurrence ranges from 1-3% among patients who don’t have any risk factors after a normal vaginal delivery, but increases to 5-6% for those with risk factors.
If a woman has a Cesarean section (C-section) to deliver her baby, the risk of postpartum endometritis increases dramatically. This is especially true if the C-section takes place after breaking of the amniotic sac (water breaking).
Using antibiotics appropriately can lower the risk of this condition. In fact, without antibiotic preventative measures, 20% of patients could develop it.
If postpartum endometritis is not treated, it could result in a fatality rate as high as 17%.

Signs and Symptoms of Endometritis

Endometritis is an inflammation of the lining of the uterus, and it can occur in several forms: acute, chronic or postpartum. Diagnosing endometritis is based on symptoms and medical examination, but the exact symptoms can differ between the types. While some patients might not show any symptoms, others may experience some characteristic indications. Therefore, taking a detailed medical history is very important for diagnosing this condition accurately. Also, signs of other related conditions, like Pelvic Inflammatory Disease (PID), may be sought during this process.

Acute endometritis typically starts suddenly with pelvic pain, painful sexual intercourse and vaginal discharge. It’s mostly seen in sexually active people, though some may not have any symptoms. Depending on the severity of the condition, there may be systemic symptoms like fever and uneasiness, but these are often not present in milder cases. Other symptoms might include unusually heavy or irregular menstrual bleeding, painful urination and discomfort after sex.

On the other hand, chronic endometritis often does not have notable symptoms. When symptoms are present, they typically can include abnormal menstrual bleeding, pelvic discomfort, and abnormal vaginal discharge. This type of endometritis often appears in people who have history of recurrent pregnancy loss, multiple failures in embryo implantation and infertility.

Postpartum endometritis is another form of this condition that happens after childbirth or miscarriage. The key symptom is fever following childbirth or miscarriage. Other symptoms of postpartum endometritis include tenderness around the uterus, significant lower abdominal pain, unusual and foul-smelling vaginal discharge after giving birth, and sluggish shrinking of uterus after birth. General discomfort, headaches, and chills may also occur.

In terms of examination, doctors usually conduct detailed abdominal and pelvic evaluations. This may include a speculum examination to check for any signs of infection, among them vaginal discharge is commonly found in cases of acute and chronic endometritis. Tender and fragile cervix is another common finding in acute endometritis cases. During a bimanual examination, the doctor checks for tenderness in uterus and its surroundings.

For postpartum endometritis, clinical findings include pronounced tenderness around the uterus and enlarged postpartum uterine size as well as indicators such as fever and rapid heart rate. In severe cases, especially those caused by certain bacteria, endometritis can advance quickly into a severe infection with various signs such as low or high body temperature, disturbed state of mind, and disruption of organ function.

Testing for Endometritis

Endometritis, which is an inflammation of the inner lining of the uterus, known as the endometrium, can either be acute (short term) or chronic (long term). Diagnosing endometritis primarily involves assessing medical history, physical examination, and risk factors. If there is doubt regarding the diagnosis, further tests such as imaging or more tests may be conducted. Issues such as persisting symptoms despite treatment, or the inability to rule out certain other medical conditions, can contribute to this uncertainty. Chronic endometritis, however, is ordinarily identified through a histologic examination, which involves studying tissue under a microscope, or through findings on a procedure called hysteroscopy.

Acute endometritis often shares symptoms with Pelvic Inflammatory Disease (PID), as endometritis can be part of PID. Because undiagnosed PID can have severe complications, the Centers for Disease Control and Prevention (CDC) recommend presumptive diagnosis and treatment of PID for individuals who show certain symptoms. For this reason, sometimes, individuals with isolated acute endometritis may be diagnosed with PID.

Tests for sexually transmitted infections and bacterial vaginosis (an infection of the vagina) are suggested. The presence of certain organisms may suggest sexually transmitted diseases, and can be detected with nucleic acid amplification tests on specimens taken from the cervix. Some kinds of infections can be diagnosed by evaluating a sample of vaginal discharge under a microscope. In places without microscope availability, molecular tests may be pursued. Patients suspected of having PID are also recommended to be screened for HIV and syphilis, due to similarities in risk factors and the likelihood of co-infections. It’s generally not needed to obtain a biopsy, which is a sample of tissue from the endometrium. Tests like erythrocyte sedimentation rate and C-reactive protein are often elevated but are nonspecific findings in this condition. Also, an increased white blood cell count is common, but in less severe cases, this count may be normal.

Imaging through a transvaginal ultrasound may be considered if patients fail to respond to appropriate antibiotic therapy. Alternatively, it can be used to rule out other diagnoses in patients with moderate to severe symptoms. In more complex cases, a pelvic CT or MRI may be used to help rule out other causes of the patient’s symptoms.

Chronic endometritis often doesn’t show serious symptoms, and so it typically diagnosed through confirming the condition by histologic or hysteroscopic examination. For this, an endometrial biopsy can be obtained and studied for the presence of endometrial stromal plasmacytes (ESPCs), a type of cell, through traditional tissue staining techniques, or using a marking technique called immunohistochemistry with marker CD138.

Postpartum endometritis refers to the condition when it occurs after childbirth. Its diagnosis implicates any patient with unexplained fever after giving birth. Early-onset endometritis has symptoms appearing within 48 hours of delivery, whereas late-onset endometritis has symptom onset within six weeks after birth. Lab tests can be beneficial in this case to rule out other similar infections or to monitor for possible progression of infection, for example, towards sepsis. However, they can’t afford surefire confirmation of endometritis. Increased white blood cell count, common immediately after childbirth, especially after cesarean delivery, can suggest infection with endometritis if the levels are significantly high. Other tests for infections, such as urinary tract infections, which share similar symptoms, may be ordered. Nevertheless, tests for endometrial cultures and cervical cells are generally not indicated, due to their relative lack of influence on treatment except in certain cases.

Imaging like pelvic ultrasound is recommended if it’s decided to pursue imaging for diagnosis. However, these rarely provide any concrete findings unless an alternative diagnosis is suspected. As a result, imaging results should be understood in correlation to the patient’s clinical history.

Treatment Options for Endometritis

Acute endometritis, a condition where the uterus lining is inflamed, is treated with several different types of antibiotics based on severity. For milder or moderate cases that can be managed at home, the doctor might prescribe a variety of antibiotic medications. If a person is allergic to certain antibiotics, alternative medications such as levofloxacin, moxifloxacin, or azithromycin combined with other drugs might be given.

In some cases, the patient might need to be admitted to the hospital. This could be due to factors like the presence of an abscess (a pocket of pus), failure of outpatient therapy, severe sickness, nausea, vomiting, high fever, or when there’s a possibility of other surgical complications. When in hospital, stronger antibiotics are usually administered intravenously (directly into the veins). These stronger antibiotics are continued till the patient shows signs of improvement, including reduced fever and abdominal pain. Once the condition improves, the patient is switched to an oral antibiotic regimen.

Chronic endometritis, a long-term uterine inflammation, is typically treated in a similar way using different types of antibiotics. If standard treatment fails, other combination drug treatments are available. For a specific type of chronic condition known as chronic granulomatous endometritis, antitubercular therapy, which includes multiple drugs, is typically recommended.

Postpartum endometritis is a similar condition that occurs after childbirth. Women showing moderate to severe symptoms or those who have given birth via cesarean are usually treated with intravenous antibiotics. The choice of antibiotic is determined and adjusted based on the person’s specific circumstances such as infection type and response to treatment. If symptoms do not improve within 72 hours, healthcare providers should consider other conditions such as pneumonia or kidney infections. Antibiotics are usually continued until the patient remains fever-free for at least 24 hours, experiencing pain reduction and resolution of white blood cell count indicative of infection. In certain cases, oral antibiotics might be considered for patients having mild symptoms identified after being discharged from the hospital.

When experiencing pelvic pain, a wide array of conditions could be the cause. These can include, but are not limited to:

Ectopic pregnancy
Complications due to an ovarian cyst
Ovarian torsion (twisted ovary)
Endometriosis
Tube-ovary infection
Bladder inflammation
Kidney stones
Problems in the gut like appendicitis, diverticulitis, or Irritable bowel syndrome.

When it comes to irregular bleeding or difficulties with fertility, doctors need to consider a range of possibilities. The American College of Obstetricians and Gynecologists (ACOG) suggest a method called the PALM-COEIN system, which breaks down the potential causes into categories like:

Polyps
Adenomyosis, a condition where the inner lining of the uterus grows into the muscular wall of the uterus
Leiomyomas (another term for fibroids)
Malignancy (cancer)
Coagulopathy, which means a bleeding disorder
Ovulatory dysfunction
Endometrial causes
Iatrogenic problems, which are caused by medical treatment
Issues that haven’t been classified yet.

For those who have recently given birth and are experiencing a fever, there are other possible explanations which include:

Wound infection from surgery
Urinary tract infections (UTIs)
Pyelonephritis, a serious kidney infection
Mastitis, inflammations in breast tissue
Pneumonia
Sepsis, a severe body reaction to infection
Peritonitis, inflammation of the lining of the abdomen
Septic pelvic thrombophlebitis, a blood clot condition with infection.

What to expect with Endometritis

If postpartum endometritis (inflammation of the inner lining of the uterus after childbirth) isn’t treated, it could potentially result in a fatality rate of around 17%. But in developed countries, with the right treatment, there’s usually a very good outcome.

Acute endometritis on its own tends to have a very good prognosis too. However, it is often found together with salpingitis (inflammation of the fallopian tubes), which can considerably heighten the risk of infertility due to issues with the fallopian tubes.

Studies show that fertility results can greatly improve with treatment for chronic endometritis (long-term inflammation of the uterus lining). For instance, in a study looking at embryo transfer procedures, success rates of live births were notably higher in treated patients – around 60% to 65% – compared to those who were untreated, where the rates were just 6% to 15%.

Another study showed that in patients who had experienced recurrent pregnancy loss and chronic endometritis, success rates of live births increased drastically- from 7% before treatment to 56% after treatment.

Possible Complications When Diagnosed with Endometritis

Acute endometritis, especially when connected to pelvic inflammatory disease (PID), can lead to infertility, constant pelvic pain, and ectopic pregnancy. This condition can also escalate to a tubo-ovarian abscess, where pus forms in the ovaries and fallopian tubes. On the other hand, chronic endometritis can create complications such as repeated loss of pregnancy, failed implantation, and abnormal uterine bleeding.

Endometritis that occurs after childbirth can also lead to serious complications in 1% to 4% of patients. These might include severe infections in the bloodstream (sepsis), abscesses, large bruises, septic pelvic thrombophlebitis (a blood clot in the pelvic veins caused by an infection), and necrotizing fasciitis, a serious infection that causes tissue death. In some instances, surgery may be required if there is a fluid collection that needs drainage.

Common Consequences:

Infertility
Constant pelvic pain
Ectopic pregnancy
Tubo-ovarian abscess
Repeated loss of pregnancy
Failed implantation
Abnormal uterine bleeding
Severe infections in the bloodstream
Abscesses
Large Bruises
Septic pelvic thrombophlebitis
Necrotizing fasciitis
Fall into the requirement to have surgery

Preventing Endometritis

Due to the high risk of getting an infection of the uterus lining (endometritis) after a cesarean delivery, and the potentially serious outcomes of this infection, the American College of Obstetricians and Gynecologists (ACOG) suggests taking preventative antibiotics before all cesarean deliveries. Recent research confirms that taking appropriate antibiotics can significantly lower the risk of infections after childbirth, including endometritis.

The ACOG advises taking a type of antibiotic called a first-generation cephalosporin, like cefazolin, through an IV once, within 1 hour before the operation. Moreover, studies show better results for patients who had a cesarean delivery after being in labor and were given another antibiotic, azithromycin, to the standard pre-surgery preventative measures. It’s important for patients to be aware of the increased risk of post-childbirth infections before having a cesarean procedure as part of the consent process.

Prevention strategies for endometritis and Pelvic Inflammatory Disease (PID, an infection of the female reproductive organs) when not pregnant include: treating a common symptom of an infection called bacterial vaginosis (BV), appropriate testing for sexually transmitted infections (STIs) in all women under 25, or those 25 or older who have a higher risk of STIs (for example, a new sexual partner, more than one sexual partner, a partner with multiple partners, or a partner who has an STI), and providing guidance on behavior for all teens and adults at a higher risk for sexually transmitted infections.

Frequently asked questions

Endometritis is a condition where the inner lining of the uterus, called the endometrium, gets inflamed. It often occurs due to an infection, and can be acute or chronic. Acute endometritis can happen without a connection to pregnancy and is often caused by sexually transmitted infections or bacterial vaginosis. Chronic endometritis is a mild inflammation of the endometrium that usually happens due to bacterial colonization not connected to pregnancy and lasts for 30 days or more.

The true prevalence of endometritis is difficult to estimate, but it can range from 1-3% among patients without risk factors after a normal vaginal delivery, and increases to 5-6% for those with risk factors.

The signs and symptoms of endometritis can vary depending on the type of endometritis. Here are the signs and symptoms for each type: 1. Acute endometritis: - Pelvic pain - Painful sexual intercourse - Vaginal discharge - Systemic symptoms like fever and uneasiness (in severe cases) - Unusually heavy or irregular menstrual bleeding - Painful urination - Discomfort after sex 2. Chronic endometritis: - Abnormal menstrual bleeding - Pelvic discomfort - Abnormal vaginal discharge - Often no notable symptoms - More common in people with a history of recurrent pregnancy loss, multiple failures in embryo implantation, and infertility 3. Postpartum endometritis: - Fever following childbirth or miscarriage - Tenderness around the uterus - Significant lower abdominal pain - Unusual and foul-smelling vaginal discharge after giving birth - Sluggish shrinking of the uterus after birth - General discomfort, headaches, and chills may also occur It's important to note that some patients may not show any symptoms, while others may experience characteristic indications. Taking a detailed medical history is crucial for accurate diagnosis, and signs of other related conditions like Pelvic Inflammatory Disease (PID) may be sought during the diagnostic process.

Endometritis can be caused by various factors, including sexually transmitted infections (STIs) such as Chlamydia trachomatis and Neisseria gonorrhoeae, high-risk sexual behavior, gynecological procedures like intrauterine devices or endometrial biopsies, intrauterine contraceptive devices, endometrial polyps, submucosal leiomyomas, childbirth, and the insertion of foreign bodies into the uterus.

When diagnosing Endometritis, a doctor needs to rule out the following conditions: 1. Ectopic pregnancy 2. Complications due to an ovarian cyst 3. Ovarian torsion (twisted ovary) 4. Endometriosis 5. Tube-ovary infection 6. Bladder inflammation 7. Kidney stones 8. Problems in the gut like appendicitis, diverticulitis, or Irritable bowel syndrome.

The types of tests that may be needed to diagnose endometritis include: - Medical history assessment - Physical examination - Risk factor assessment - Tests for sexually transmitted infections and bacterial vaginosis - Nucleic acid amplification tests on specimens taken from the cervix - Evaluation of a sample of vaginal discharge under a microscope - Screening for HIV and syphilis - Transvaginal ultrasound - Pelvic CT or MRI - Endometrial biopsy - Histologic examination - Hysteroscopic examination - Lab tests to rule out other infections or monitor for progression - Increased white blood cell count - Tests for urinary tract infections - Pelvic ultrasound It is important to note that not all of these tests may be necessary for every case of endometritis, and the specific tests ordered will depend on the individual patient's symptoms and circumstances.

Endometritis is treated with a variety of antibiotics, which are prescribed based on the severity of the condition. For milder or moderate cases that can be managed at home, a variety of antibiotic medications may be prescribed. If a person is allergic to certain antibiotics, alternative medications such as levofloxacin, moxifloxacin, or azithromycin combined with other drugs might be given. In more severe cases, hospital admission may be necessary, and stronger antibiotics are usually administered intravenously. Once the condition improves, the patient is switched to an oral antibiotic regimen. Chronic endometritis is treated in a similar way, and if standard treatment fails, other combination drug treatments are available. For postpartum endometritis, intravenous antibiotics are usually given, and the choice of antibiotic is determined based on the person's specific circumstances.

The side effects when treating Endometritis can include infertility, constant pelvic pain, ectopic pregnancy, tubo-ovarian abscess, repeated loss of pregnancy, failed implantation, abnormal uterine bleeding, severe infections in the bloodstream, abscesses, large bruises, septic pelvic thrombophlebitis, necrotizing fasciitis, and the possibility of requiring surgery.

The prognosis for endometritis varies depending on the type: - Acute endometritis on its own tends to have a very good prognosis. - Chronic endometritis can be treated, and studies have shown that fertility results can greatly improve with treatment. - Postpartum endometritis, if left untreated, could potentially result in a fatality rate of around 17%. However, with the right treatment, there is usually a very good outcome in developed countries.

You should see a gynecologist for Endometritis.