What are the diagnosis, ultrasound findings, and treatment options for chronic endometritis?

Chronic Endometritis: Diagnosis, Ultrasound Findings, and Treatment

Chronic endometritis (CE) is a persistent, low-intensity inflammation of the endometrial mucosa characterized by plasma cell infiltration into the endometrial stroma, which is typically a consequence of bacterial infection. Hysteroscopy should be considered the gold standard diagnostic tool for chronic endometritis due to its high correlation with histological findings and excellent sensitivity (86-100%) and negative predictive value (92-100%). 1

Diagnosis of Chronic Endometritis

Diagnostic Methods

• Histopathological examination: The traditional gold standard involves identifying plasma cells in the endometrial stroma through endometrial biopsy 2, 3
• Immunohistochemistry: Recommended alongside conventional histology to increase diagnostic accuracy by better identifying plasma cells 2
• Hysteroscopy: Considered highly reliable with sensitivity over 86% and negative predictive value over 92%, allowing direct visualization of inflammatory signs 1
• Molecular microbiology: Real-time PCR techniques can identify culturable and non-culturable pathogens associated with CE with 75% sensitivity and 100% specificity when compared with combined traditional methods 4

Hysteroscopic Findings in Chronic Endometritis

• Focal or diffuse hyperemia: Localized or widespread redness of the endometrial surface 1
• Stromal edema: Swelling of the endometrial tissue 1
• Micropolyps: Small polyp-like projections on the endometrial surface 1
• Strawberry aspect: Characteristic appearance of the endometrium with multiple small red spots resembling a strawberry surface 1

Ultrasound Findings

• Transvaginal ultrasound may show:
  • Irregular endometrial thickening 5
  • Fluid in the endometrial cavity 5
  • Heterogeneous endometrial echogenicity 5
• However, ultrasound findings are often non-specific and have limited sensitivity for diagnosing CE 5

Clinical Significance and Impact

• CE is more prevalent in infertile patients and is associated with:

  • Recurrent implantation failure 2, 6
  • Recurrent pregnancy loss 2, 6
  • Unexplained infertility 1

• Pathophysiological mechanisms include:

  • Altered leukocyte populations in the endometrium 2
  • Abnormal cytokine production affecting implantation 2
  • Disrupted growth factor expression impacting endometrial receptivity 2

Treatment Approach

• Antibiotic therapy: The mainstay of treatment for CE 2

  • Effective antibiotic treatment improves pregnancy rates and live birth rates in patients with recurrent pregnancy loss 2
  • Increases ongoing pregnancy rates in patients with recurrent implantation failure 2

• Targeted antimicrobial therapy:

  • Should provide broad-spectrum coverage against common pathogens including Enterobacteriaceae, Enterococcus, Streptococcus, Staphylococcus, Mycoplasma, and Ureaplasma 4
  • Treatment should be guided by microbial culture or molecular testing results when available 4

Clinical Recommendations

• Consider CE evaluation in patients with:

  • Unexplained infertility 1
  • Recurrent implantation failure 1
  • Recurrent pregnancy loss 1

• Diagnostic approach should combine:

  • Hysteroscopy for visual assessment of the endometrium 1
  • Endometrial biopsy with immunohistochemistry for plasma cell identification 2, 3
  • Microbial culture or molecular testing to identify causative pathogens 4

• Follow-up after treatment:

  • Consider repeat hysteroscopy or biopsy to confirm resolution of inflammation 1
  • Monitor for improvement in reproductive outcomes 2

Challenges and Limitations

• Lack of standardized diagnostic criteria for CE 3
• Histopathological examination may underdiagnose while hysteroscopy may overdiagnose CE 1
• Not all causative microorganisms are easily culturable, requiring specialized molecular techniques 4
• CE is often asymptomatic or presents with non-specific symptoms, leading to underdiagnosis 2, 3