Chronic Endometritis

Chronic endometritis is persistent inflammation of the endometrium, shown by plasma cells in the endometrial stroma on biopsy.

• Causes include bacteria (Streptococcus, Escherichia coli, Enterococcus, Mycoplasma, Ureaplasma, Chlamydia), intrauterine devices, retained products of conception and tuberculosis.
• It is associated with abnormal bleeding, infertility, recurrent implantation failure and recurrent miscarriage.
• It is often silent.

Intermenstrual spotting, heavy menstrual bleeding, pelvic pain, dyspareunia, vaginal discharge or infertility; many women have no symptoms.

• Pelvic examination is often normal; mild uterine tenderness is possible.
• Differential diagnosis: endometrial polyp, hyperplasia, submucosal fibroid, pelvic inflammatory disease, genital tuberculosis, retained products of conception, endometriosis.
• Complications: infertility, recurrent miscarriage, implantation failure, preterm birth, chronic pelvic pain.

Diagnosis is by endometrial biopsy with CD138 staining, supported by hysteroscopy.

• Endometrial biopsy with CD138 immunostaining for plasma cells (five or more plasma cells per 10 high-power fields is a commonly used threshold).
• Hysteroscopy showing hyperaemia, stromal oedema and micropolyps.
• NAAT for chlamydia and gonorrhoea; high vaginal and endocervical swabs; culture of endometrial tissue where available.
• Xpert MTB/RIF and histology for tuberculosis in endemic settings or with infertility; HIV and syphilis tests.
• Pregnancy test.

Treat with a 14-day antibiotic course, remove any cause, and confirm cure by repeat biopsy.

• Supportive: partner testing and treatment where infection is found; abstain from intercourse during treatment; remove any intrauterine device.
• Pharmacological: doxycycline 100 mg oral 12-hourly for 14 days. If persistent: ciprofloxacin 500 mg oral 12-hourly plus metronidazole 400 mg oral 12-hourly for 14 days; or amoxicillin-clavulanate 625 mg oral 8-hourly for 14 days. If Mycoplasma is found, add azithromycin 1 g oral on day 1 then 500 mg daily for 2 days. For genital tuberculosis: isoniazid 5 mg/kg (maximum 300 mg), rifampicin 10 mg/kg (maximum 600 mg), pyrazinamide 25 mg/kg and ethambutol 15 mg/kg, all oral once daily for 2 months, then isoniazid and rifampicin once daily for 4 months, with pyridoxine 25 mg oral daily.
• Procedures: hysteroscopic removal of polyps or retained tissue; repeat biopsy at 4 to 6 weeks after antibiotics to confirm cure.
• Special groups: in pregnancy avoid doxycycline and ciprofloxacin; use amoxicillin-clavulanate 625 mg oral 8-hourly for 14 days or azithromycin 1 g oral single dose. In HIV infection on dolutegravir, give dolutegravir 50 mg oral twice daily during rifampicin treatment. In liver impairment monitor liver enzymes on tuberculosis drugs.
• Red flags: fever, pelvic mass, persistent bleeding, treatment failure, pelvic tuberculosis features.
• Follow-up: repeat biopsy at 4 to 6 weeks; second course for persistent plasma cells; fertility review at 3 months.