Endometrial inflammation, also known as endometritis, refers to inflammation of the endometrium, which is the inner lining of the uterus. This condition can occur due to several causes and can lead to issues with fertility if not properly treated. Some quick answers to questions about endometrial inflammation include:
– What part of the body is affected? The endometrium, which is the inner lining of the uterus.
– What are the symptoms? Symptoms may include pelvic pain, bleeding or spotting between periods, painful sexual intercourse, and abnormal vaginal discharge.
– Who is at risk? Those at higher risk include people who have recently given birth, have had miscarriages or abortions, use an intrauterine device (IUD) for birth control, or have conditions like endometriosis or pelvic inflammatory disease.
– How is it diagnosed? Diagnosis is made through a pelvic exam, imaging tests, or a biopsy of the endometrium.
– How is it treated? Treatment involves antibiotics to clear the infection along with other medications to reduce inflammation.
In the sections below, we will explore the causes, symptoms, diagnosis, and treatment of endometrial inflammation in more detail.
Causes
There are several potential causes of endometrial inflammation, including:
Infection
One of the most common causes of endometritis is infection of the endometrium, typically by bacteria. The bacteria most often involved are:
– Gonorrhea
– Chlamydia
– Staphylococcus
– Streptococcus
– E. coli
– Bacterial vaginosis
These bacteria may be introduced into the uterus during medical procedures such as:
– Childbirth
– Miscarriage or abortion
– Endometrial biopsy
– Hysteroscopy
– IUD insertion
The cervix serves as a barrier to protect the uterus from bacteria normally present in the vagina. However, cervical dilation during these procedures allows bacteria to enter the uterus and infect the endometrium.
Foreign Objects
Having a foreign object in the uterus may also lead to endometritis. Objects that can cause inflammation include:
– Intrauterine devices (IUDs) – The presence of the IUD itself may trigger inflammation, but IUDs also raise the risk of infection.
– Forgotten tampons – Leaving a tampon in too long allows bacteria to grow and spread.
– Internal scar tissue – Scarring from prior infections, procedures or injury can obstruct areas and prevent proper drainage, leading to bacterial overgrowth.
Autoimmune Reaction
Sometimes the immune system may attack the lining of the uterus, seeing it as a foreign substance. This autoimmune reaction leads to inflammation without infection. Conditions associated with this response include:
– Endometriosis – Tissue similar to the uterine lining growing outside the uterus may trigger an abnormal immune reaction.
– Allergic reactions – Allergies to sanitary products, spermicides, or other agents may cause inflammation.
– Chronic endometritis – Repeated bouts of endometritis from unresolved causes can lead to chronic inflammation.
Hormonal Imbalances
Hormonal problems may also contribute to endometrial inflammation in some cases. Issues include:
– Low estrogen levels – Thinning of the endometrium from low estrogen after menopause or from athletic training can lead to irritation.
– Polycystic ovarian syndrome (PCOS) – Higher androgen levels from this hormonal disorder are associated with chronic endometritis.
– Hypothyroidism – An underactive thyroid slows cell turnover in the endometrium, which may impair healing.
Cancer
Rarely, inflammation of the endometrium may be the first warning sign of cancers such as endometrial cancer or uterine sarcoma. However, cancer accounts for less than 1% of endometritis cases.
Irritation
Physical irritation from objects directly contacting the endometrium may also cause inflammation. Sources include:
– An improperly sized IUD
– Surgical instruments during hysteroscopy
– Uterine polyps or fibroids
In many cases, endometritis results from a combination of factors rather than just one cause. For example, a postpartum infection may occur because an object like a retained placenta fragment irritates the lining and allows bacterial overgrowth. identifying all contributing causes ensures proper treatment.
Risk Factors
Certain individuals have a higher risk of developing endometritis. Risk factors include:
– Recent childbirth – The dilated cervix and placental detachment after delivery allow bacteria to enter the uterus easily. About 1-3% of people develop endometritis after vaginal birth, while up to 27% develop it after a cesarean section.
– Recent miscarriage or abortion – Similar to childbirth, the dilated cervix during these procedures increases infection risk. Up to one-third of those with missed or incomplete miscarriages get endometritis.
– Intrauterine devices (IUDs) – Around 15% of IUD users develop pelvic infections like endometritis within three months after insertion. The IUD string can allow bacteria to wick into the uterus.
– Invasive uterine procedures – Any procedure entering the uterus may introduce bacteria, including hysteroscopy, dilation and curettage (D&C), endometrial biopsy or hysterectomy.
– Multiple sexual partners – Higher numbers of sexual partners raise the odds of getting a sexually transmitted bacterial infection that ascends into the uterus.
– Douching – Cleaning the vagina, especially after menstruation, may force bacteria further upward.
– Use of vaginal spermicides – Chemical irritants in spermicides like nonoxynol-9 can damage vaginal cell walls and increase infection susceptibility.
– Previous pelvic infections – Having pelvic inflammatory disease, cervicitis or vaginitis causes inflammation that allows for easier bacterial ascent into the uterus.
– Endometriosis – The presence of uterine tissue outside the uterus may promote abnormal immune reactions and chronic inflammation.
Symptoms
The signs and symptoms of endometrial inflammation may include:
– Pelvic pain – Lower abdominal cramping is common, either during the menstrual period or between cycles. The pain may radiate to the lower back and thighs as well.
– Vaginal bleeding – Spotting between periods occurs frequently. Heavy bleeding is also possible along with passing blood clots.
– Vaginal discharge – A yellow, green or grey discharge may have a foul fishy odor. There may be increased discharge overall.
– Painful sexual intercourse – Penetration deepens the pelvic discomfort. Sex may also irritate inflamed areas and cause light bleeding or spotting afterward.
– Fever and chills – About 20-30% of people with endometritis run a fever over 100.4°F (38°C). Fevers indicate the body is fighting infection.
– General malaise – Those with endometritis often feel extremely tired and rundown. Fatigue results both from the inflammation and the body’s efforts to heal.
– Urinary issues – Dysuria or urgency with urination may occur if inflammation spreads to surrounding pelvic structures like the bladder.
Symptoms After Childbirth
Endometritis after giving birth has some unique symptoms to watch for:
– Uterine tenderness – The lower abdomen is sore and hurts significantly when touched. Even a light graze over the area causes sharp pain.
– Heavy lochia – Lochia is the postpartum vaginal discharge containing blood, mucus and placental tissue. This discharge stays heavy and bright red past 10 days after delivery with endometritis.
– Gastrointestinal upset – About 1 in 3 cases involve diarrhea, nausea and vomiting from the systemic infection.
– Breastfeeding issues – Milk supply may decrease. Breasts feel tender and swollen as inflammation impairs milk ejection.
Postpartum endometritis requires quick treatment. Symptoms typically develop anywhere from 24 hours to 7 days after giving birth. Around 2% of people develop severe sepsis, so prompt medical care is vital.
Diagnosis
If endometritis is suspected, the doctor will begin with a detailed medical history and pelvic examination. They may then use the following tests to confirm diagnosis:
Pelvic Exam
The examiner will look for:
– Uterine tenderness – Pressing on the uterus causes pain.
– Abnormal vaginal or cervical discharge – Signs of yellow, green or grey discharge indicate infection.
– Cervical motion tenderness – Movement of the cervix during the exam exacerbates pain.
– Adnexal tenderness – Discomfort of the adnexa suggests spreading inflammation. The adnexa include the ovaries, fallopian tubes and supporting ligaments.
Microscopy
A sample of the vaginal discharge is observed under a microscope. The presence of:
– Increased white blood cells – Indicates the body is fighting infection.
– Clue cells – Vaginal epithelial cells encircled with bacteria point to bacterial vaginosis, which spreads infection to the uterus.
– Trichomonas – The protozoan parasite causes vaginitis and spreads upwards.
Microbial Testing
Cultures may be taken to identify the specific bacteria involved:
– Endometrial biopsy – Using a thin catheter, a small sample of the endometrial lining is collected to culture.
– Vaginal swab – Swabbing the vagina can reveal microbial vaginosis and sexually transmitted infections.
– Cervical swab – Similar to a vaginal swab, this can help find gonorrheal or chlamydial infection.
– Blood culture – If fever is present, a blood sample is cultured to identify bacteria in the bloodstream.
Saline Infusion Sonography
This technique uses ultrasound imaging of saline injected into the uterine cavity to identify:
– Abnormal fluid accumulation
– Uterine polyps or fibroids
– Thickened endometrium
Hysteroscopy
A hysteroscope inserted in the uterus allows direct visualization of the endometrial lining to check for inflammation or abnormal growths.
Endometrial Biopsy
Removing a small sample of the endometrium for laboratory testing can confirm endometritis by the presence of:
– Plasma cells – These cells produce antibodies to fight infection.
– Neutrophils – Increased neutrophils battle bacterial invaders.
– Lymphatic dilation – Swollen lymphatic channels results from inflammation.
Treatment
Treating endometritis involves clearing up the infection and controlling inflammation. Treatment methods may include:
Antibiotics
Antibiotics administered through an IV or orally combat the underlying bacterial infection. Broad spectrum antibiotics provide protection against gonorrhea, chlamydia, bacterial vaginosis and other common causes while waiting for culture results. Once lab results identify the specific bacteria, more targeted antibiotics can be prescribed.
Common antibiotics used include:
– Doxycycline
– Azithromycin
– Cefoxitin
– Clindamycin
– Metronidazole
– Gentamicin
– Vancomycin
It is critical to finish the entire antibiotic course, even if symptoms resolve earlier. This prevents resistance and ensures the infection clears completely. People with severe penicillin allergies may need alternative antibiotics.
NSAIDs
Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen help reduce inflammation and pain in the pelvic region. NSAIDs inhibit prostaglandins that trigger uterine muscle contraction and pain sensations.
Opioid Pain Relievers
For severe pelvic and abdominal pain, short-term opioid medications like hydrocodone may be prescribed in combination with NSAIDs. They should be used for less than a week until inflammation subsides.
Intravenous Fluids
IV fluid administration provides hydration and flushes the system of bacteria. Fluids are given for at least 24-48 hours for more severe generalized infections along with antibiotics.
Surgery
Surgery may be required if conservative treatments fail to clear the infection. Procedures like dilation & curettage (D&C) remove adhesions or foreign objects like retained placental bits after childbirth. Abscesses may need to be drained. Hysterectomy is an extremely rare last resort.
Hormone Therapy
If hormonal problems contribute to chronic endometritis, hormonal medications can help regulate the uterine environment. Low-dose estrogen creams or oral contraceptives may be used to stabilize the uterine lining after infection clears.
Complications
Endometritis may lead to various complications if left untreated:
– Infertility – Swelling and scarring from repeated bouts of inflammation can permanently damage the endometrium, preventing implantation of a fertilized egg.
– Recurrent miscarriage – Up to 5% of people with recurrent pregnancy loss have chronic endometritis that interferes with embryo implantation.
– Pelvic adhesions – Inflammation may cause scar tissue binding together internal pelvic structures. This also impairs fertility.
– Chronic pelvic pain – Persistent inflammation can lead to lasting pelvic floor muscle spasms and nerve pain.
– Sepsis – Bacteria may spread through the bloodstream and progress to life-threatening sepsis. Postpartum endometritis carries the highest risk for sepsis.
– Abscess formation – Walled off pockets of pus called abscesses may develop in nearby areas like the ovaries or fallopian tubes if bacteria spread.
– Septic shock – Overwhelming infection can result in dangerously low blood pressure from septic shock. This complication has a mortality rate around 40%.
– Septic thrombophlebitis – Infection of pelvic veins leads to thrombosis and tissue death. Septic emboli can travel through the circulation and obstruct blood flow.
Prompt diagnosis and treatment provide the best chance of clearing infection before these severe complications develop. People with recurrent or treatment-resistant endometritis may need evaluation for underlying causes like fibroids, polyps or endometriosis.
Prevention
While not all cases can be prevented, the following measures lower endometritis risk:
– Practicing safe sex – Using condoms reduces exposure to sexually transmitted infections that can spread to the uterus.
– Avoiding douching – Douching changes the vaginal flora balance and may force bacteria upward.
– Removing IUDs before expiration – Preventing IUDs from staying in too long lowers infection risk.
– Careful cleansing after menses – Changing pads frequently and proper perineal hygiene during periods reduces bacterial overgrowth.
– Promptly removing retained tampons – Never leaving tampons in for over 8 hours avoids excessive bacterial buildup.
– Optimal diabetes control – Poorly managed diabetes increases susceptibility to infection. Maintaining blood sugar levels prevents complications.
– Breastfeeding after delivery – Nursing helps the uterus contract and return to normal size faster, which reduces bleeding and infection risk.
– Probiotic use – Oral or vaginal probiotics may promote protective vaginal lactobacilli to displace dangerous bacteria.
While some cases are unavoidable, paying close attention to gynecologic health helps minimize risks for endometritis. Any abnormal bleeding, discharge or pelvic pain warrants medical evaluation to identify the cause. Treating any infections or abnormalities preconception may prevent endometritis from complicating future pregnancies.
Conclusion
Endometritis refers to inflammation of the endometrium, the inner uterine lining. It results from overgrowth of bacteria that enter the uterus after childbirth, abortion, or procedures like IUD insertion or hysteroscopy. Autoimmune issues, foreign objects like IUDs, and hormonal imbalances may also spark inflammation without infection.
Symptoms include pelvic pain, abnormal vaginal bleeding and discharge, pain during sex, and postpartum uterine tenderness. Diagnosis relies on a pelvic exam, microbial testing and imaging or biopsy of the endometrium.
Treatment involves antibiotics to clear infection, NSAIDs to reduce inflammation, and surgery in rare recalcitrant cases. Prompt treatment is vital to prevent complications like infertility, chronic pelvic pain, abscesses and potentially fatal sepsis.
Prevention aims to limit bacterial introduction into the uterus through safe sexual practices and optimal vaginal hygiene. While endometritis is a relatively common gynecologic condition, identifying risk factors and adhering to screening recommendations allows for early diagnosis and treatment to optimize outcomes.