Commonly used diagnostic criteria for pelvic inflammatory disease have poor sensitivity for plasma cell endometritis

The Diagnostic Criteria for Chronic Endometritis: A Survey of Pathologists

While acute endometritis is a reasonably well-defined entity of ascending infection and attendant active inflammation, chronic endometritis is less well defined. As part of a broad effort to define and refine the diagnostic criteria and management of the disease, we conducted a survey of pathologists to understand the variability in diagnostic criteria and implications of the diagnosis of nonspecific, nonobstetric chronic endometritis. Members of national and international professional pathology societies were surveyed utilizing anonymous electronic surveys designed to examine diagnostic criteria, etiological understanding and treatment implications of a pathologic diagnosis of nonspecific, nonobstetric chronic endometritis. There was substantial variability among pathologists in the diagnostic criteria used for making a diagnosis of nonspecific, nonobstetric chronic endometritis, with 28.5% of pathologists using the presence of a single plasma cell for making the diagnosis. There was additional variability in the use of special stains, reporting in the presence of coexisting lesions and the hormonal stage of the endometrium. There were no differences between generalists and specialists in the diagnostic criteria used, except the significantly greater likelihood of specialists making the diagnosis in gestational endometrium. The substantial variability in diagnostic criteria for nonspecific, nonobstetric chronic endometritis among pathologists, including among gynecologic pathologists, has the potential to confound the management of patients. Standardization of diagnostic criteria for chronic endometritis is essential to understand the implications of the diagnosis.

Etiology and Diagnosis of Pelvic Inflammatory Disease: Looking Beyond Gonorrhea and Chlamydia

Pelvic inflammatory disease (PID) is a clinical syndrome that has been associated with a wide range of potential causal pathogens. Three broad groups of organisms have been isolated from the genital tract of people with PID: sexually transmitted organisms such as Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis; bacterial vaginosis (BV)-associated species and genera such as Atopobium vaginae, Sneathia, and Megasphaera; and genera and species usually associated with the gastrointestinal or respiratory tracts such as Bacteroides, Escherichia coli, Streptococcus, or Haemophilus influenza. Although PID is often considered to be synonymous with gonorrhea or chlamydia, these pathogens are found in only one quarter to one third of people with PID, suggesting that broader screening and diagnostic and treatment strategies need to be considered to reduce the burden of PID and its associated sequelae.

Chronic endometritis and infertility

Chronic endometritis (CE) is a condition involving the breakdown of the peaceful co-existence between microorganisms and the host immune system in the endometrium. A majority of CE cases produce no noticeable signs or mild symptoms, and the prevalence rate of CE has been found to be approximately 10%. Gynecologists and pathologists often do not focus much clinical attention on CE due to the time-consuming microscopic examinations necessary to diagnose CE, its mild clinical manifestations, and the benign nature of the disease. However, the relationship between CE and infertility-related conditions such as repeated implantation failure and recurrent miscarriage has recently emerged as an area of inquiry. In this study, we reviewed the literature on the pathophysiology of CE and how it may be associated with infertility, as well as the literature regarding the diagnosis and treatment of CE. In addition, we discuss the value of hysteroscopic procedures in the diagnosis and treatment of CE.

Performance of clinical and laparoscopic criteria for the diagnosis of upper genital tract infection

Objective: The purpose of this study was to validate the standard minimal clinical criteria and the laparoscopic triad of tubal edema, erythema, and purulent exudate used to diagnose acute upper genital tract infection.

Methods: Subjects included women who either met the Centers for Disease Control and Prevention's (CDC) minimal criteria for acute pelvic inflammatory disease or had other signs of upper genital tract infection (i.e., atypical pelvic pain, abnormal uterine bleeding, or cervicitis). The subjects were evaluated with a baseline interview comprehensive laboratory testing, and either an endometrial biopsy or laparoscopy with endometrial and fimbrial biopsies for definitive diagnosis of upper genital tract infection. Patients were considered positive for upper genital tract infection if they had any of the following findings: 1) histologic evidence of endometritis or salpingitis; 2) laparoscopic visualization of purulent exudate in the pelvis without another source; or 3) positive testing for Neisseria gonorrhoeae or Chlamydia trachomatis from the endometrium, fallopian tubes, or pelvis.

Results: One hundred twenty-nine women with adequate endometrial samples were evaluated between August 1993 and September 1997, and 62 had complete laparoscopic evaluations. The sensitivities of the CDC's minimal clinical criteria for pelvic inflammatory disease and the laparoscopic triad of edema, erythema, and purulent exudate were 65% and 60%, respectively.

Conclusions: Commonly used minimal clinical criteria for pelvic inflammatory disease and the laparoscopic triad of tubal edema, erythema, and purulent exudate have limited sensitivity with correspondingly high false negative rates.

Endometrial histopathology in patients with laparoscopic proven salpingitis and HIV-1 infection

Study Objective. To identify sensitive and specific histological criteria for endometritis in women with laparoscopically-confirmed acute salpingitis. Methods. Women, age 18–40 years of age presenting with complaints of lower abdominal pain ≤2 weeks and no antibiotics use in past two weeks, were enrolled. They underwent clinical examination, screening for HIV; other sexually transmitted infections plus endometrial biopsy sampling for histopathology. Diagnostic laparoscopy confirmed the diagnosis of acute salpingitis. Controls were women undergoing tubal ligation and HIV-1 infected women asymptomatic for genital tract infection. Results. Of 125 women with laparoscopically-confirmed salpingitis, 38% were HIV-1 seropositive. Nineteen HIV-1 negative controls were recruited. For the diagnosis of endometritis, ≥1 plasma cells (PC) and ≥3 polymorphonuclear lymphocytes (PMN) per HPF in the endometrium had a sensitivity of 74% for HIV-1-seropositive, 63% for HIV-1-seronegative women with a specificity of 75% and positive predictive value of 85% regardless of HIV-1-infection for predicting moderate to severe salpingitis. For HIV-1-seronegative women with mild salpingitis, ≥1 PC and ≥3 PMN had a sensitivity of 16% and a PPV of 57%. Conclusion. Endometrial histology, did not perform well as a surrogate marker for moderate to severe salpingitis, and failed as a surrogate marker for mild salpingitis.

Diagnosis of chronic endometritis in biopsies with stromal breakdown

Plasma cells are the hallmark of chronic endometritis but are not specific for upper tract infection. Plasma cells have also been noted in hormonally mediated endometrial disorders in association with gland architectural changes ("disordered proliferative" and "anovulatory" patterns), and stromal breakdown. We reviewed benign endometrial biopsies diagnosed at Beth Israel Deaconess Medical Center over a 2-year period described as disordered/anovulatory patterns +/- stromal breakdown. Cases were excluded if tissue was not available; women were younger than 50 years where most diagnoses were atrophic or cancer; or diagnoses were secretory, menstrual endometrium, or polyps. The remaining 61 cases were compared to 33 samples of unremarkable proliferative endometrium. Plasma cells were quantified on hematoxylin and eosin-stained sections and using a histochemical stain methyl green pyronin. The indication for biopsy was an abnormal pattern of bleeding in 34 cases, infertility workup in 7, incidental part of workup for pain, or other findings in 5. The majority of disordered proliferative endometrium had plasma cells (61% grade 1, 17% grade 2) all seen on methyl green pyronin staining only. Two thirds of proliferative endometrium with breakdown showed plasma cells (19% grade 1, 39% grade 2, 10 % grade 3). Plasma cells were rare in inactive endometrium and noted in only 18% of unremarkable proliferative endometrium, all grade 1. Plasma cells are commonly present in the endometrium of women with dysfunctional uterine bleeding and focal stromal breakdown. Given the lack of clinical evidence for infection, the inflammation likely represents a physiologic process.

Prevalance of Chlamydia trochomatis, Ureaplasma urealyticum and Mycoplasma hominis infections in the unexplained infertile women

OBJECTIVE

To prospectively investigate the prevalence of Chlamydia trachomatis (CT), Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU) in the cervical canal and pouch of Douglas in unexplained infertile women and compare it to healthy controls in the Turkish population.

MATERIALS AND METHODS

A total of 31 women presenting with a history of infertility [n = 24 (77%) primary infertility, n = 7 (23%) secondary infertility] between 20 and 38 years of age and 31 women willing to have tubal ligation between 30 and 41 years of age were consecutively included into this study. Specimens were taken from intra-abdominal washings and from the cervical canal. CT, MH and UU were detected with polymerase chain reaction (PCR).

RESULTS

Results of 62 women were analyzed. None of the participants met the criteria for salpingitis during laparoscopy. The most common infection in the cervical canal in both groups was UU, which was detected in 13 cases of infertile patients and 11 controls (P = 0.602). Cervical chlamydial and mycoplasmic infection was detected in one case each in infertile and control patients. Neither MH nor UU were obtained from the pouch of Douglas in both groups. Only CT was present in peritoneal fluid of an infertile woman who had also a concomitant chlamydial infection in the cervical canal.

CONCLUSION

Demonstration of cervical colonization of CT by PCR may be a promising method for the detection of asymptomatic pelvic infection in patients with unexplained infertility. However, screening for MH and UU is not cost-effective due to similar low rates of detection.

Preconceptional antibiotic treatment to prevent preterm birth in women with a previous preterm delivery

This article addresses the question of whether the uterine cavity is normally sterile and reviews the difficulties in conducting microbiologic studies of the endometrium, the limitations of conventional microbiologic techniques (cultivation-dependent), and the potential contribution of molecular microbiology to examine microbial diversity and burden of the endometrium. Issues pertaining to the diagnosis of chronic endometritis and the need for information about the prognostic value of this finding in subsequent pregnancies are discussed. The results of a randomized clinical trial of antibiotic administration versus placebo in women with a previous preterm birth are reviewed and commentary is provided. The emerging picture is that microbial-host interactions in the endometrial cavity are important for reproductive success. This is a US government work. There are no restrictions on its use.

Genital tract infections and the specialist gynaecologist: a survey of perception, diagnosis and treatment

The study was designed to investigate the attitude of gynaecologists to the management of genital tract infections in the North West Region of England. A postal questionnaire was sent to all members and fellows of The Royal College of Obstetricians and Gynaecologists with addresses in the region. A response rate of 71% was achieved. Of these 67% were male and more than 97% had been in the speciality for more than 5 years. Only 90.5% routinely obtain swabs from the posterior fornix; none from the pharynx. Forty-two per cent thought there might be a role for the genitourinary physician in the management of genital tract infections. Nineteen per cent engaged in consort tracing and only 22.6% carried out tests of cure before discharging the patients. Fifty-one per cent thought there could be grounds for litigation for not carrying out contact tracing and 27.4% agreed that not doing tests of cure may be regarded as negligence. This study revealed that there is a need for adequate training of gynaecologists with regards to the facilities available within the National Health Service.

Histologic Endometritis in Asymptomatic Human Immunodeficiency Virus–Infected Women

OBJECTIVE

To estimate the prevalence, risk factors, clinical symptoms and signs, and response to antimicrobial therapy of histologic endometritis in human immunodeficiency virus (HIV)-infected women without clinical salpingitis.

METHODS

This was a cross-sectional study of 42 HIV-infected women enrolled from a single clinic. Subjects underwent standardized history, examination, and laboratory determinations, including endometrial biopsy. Women with suspected pelvic inflammatory disease were excluded. All women were given antibiotics and repeat evaluation in 5-7 weeks. Histologic endometritis was defined by at least one stromal plasma cell per 120x field and five or more surface polymorphonuclear leukocytes per 400x field. Chi-square and Fisher exact tests were used as appropriate.

RESULTS

Histologic endometritis was present among 16 (38%) of 42 evaluable HIV-infected women, none of whom had Chlamydia trachomatis or Neisseria gonorrhoeae. Douching three or more times per month, history of ectopic pregnancy, and two or more prior urinary tract infections were associated with endometritis, as was elevated erythrocyte sedimentation rate (P < or = .05). Physical examination findings and mean CD4+ lymphocyte count were similar among those with and without endometritis. In the nine HIV-infected women with a repeat biopsy, endometritis decreased from four (44%) to two (22%) after treatment (P = .30).

CONCLUSION

The prevalence of histologic endometritis in HIV-infected women was high despite few examination findings and no demonstrated pathogens. Endometritis in HIV-infected women might be related to pathogens not evaluated, to prior infection, or to reduced immunity from HIV.

Endometritis: the clinical-pathologic syndrome

OBJECTIVE

The purpose of this study was to evaluate histologically proved endometritis as a clinical syndrome that is distinct from laparoscopically confirmed salpingitis.

STUDY DESIGN

This was a cross-sectional study of 152 women in an urban hospital with a suspected pelvic inflammatory disease. All women provided a standardized medical history and underwent physical examination, endometrial biopsy, and laparoscopy. We defined endometritis by the presence of plasma cells in endometrial stroma and neutrophils in the endometrial epithelium.

RESULTS

Of 152 women who were enrolled, 43 women had neither endometritis nor salpingitis; 26 women had endometritis alone without salpingitis, and 83 women had salpingitis. Those women with endometritis alone more often had douched recently, had a current intrauterine device, and were in menstrual cycle day 1 to 7, compared with women with no endometritis or salpingitis (P =.007,.04,.005, respectively) or women with acute salpingitis (P =.03,.01,.02, respectively). Infection with Neisseria gonorrhoeae and/or Chlamydia trachomatis was found more frequently in women with endometritis alone than in women with no endometritis or salpingitis (P <.001) and less frequently than in women with salpingitis (P =.05). Lower quadrant, adnexal, cervical motion, rebound tenderness, peritonitis, tenderness score, fever, and laboratory abnormalities that indicated inflammation and detection of gonorrheal or chlamydial infection were significantly less common in women with endometritis alone than in women with salpingitis but were somewhat more common in women with endometritis alone than among women with no salpingitis or endometritis.

CONCLUSION

Among women with suspected pelvic inflammatory disease, the histopathologic manifestations of endometritis were associated with clinical manifestations, infection, and specific risk factors that were intermediate in frequency between women with salpingitis and women with neither endometritis nor salpingitis.

Plasma cells in chronic endometritis are easily identified when stained with syndecan-1

BACKGROUND

Chronic endometritis has been observed in 3-10% of women with irregular uterine bleeding who undergo endometrial biopsy. The diagnosis of chronic endometritis rests on the recognition of plasma cells in endometrial tissue that may show a prominent spindle cell stromal component, and is frequently difficult to date. Syndecan-1 is a cell-surface proteoglycan that is expressed on the cell surface of plasma cells.

DESIGN

Eighteen endometrial curettage cases with the diagnosis of chronic endometritis and 25 endometrial curettage cases of dysfunctional uterine bleeding, in females under the age of thirty-five in whom no other histopathologic changes were noted, were reviewed for the presence of plasma cells. Sections were then stained with syndecan-1.

RESULTS

All of the chronic endometritis cases showed easily visible syndecan-1 staining of plasma cell membranes. None of the cases of dysfunctional uterine bleeding showed presence of plasma cells in either the hematoxylin and eosin stained or syndecan-1 stained sections.

CONCLUSIONS

In cases of suspected chronic endometritis in which no plasma cells can be found on hematoxylin and eosin stained slides, syndecan-1 may be an effective adjunct in the identification of plasma cells and thus aid in the diagnosis of chronic endometritis.

Association of lower genital tract inflammation with objective evidence of endometritis

The purpose of this report is to evaluate the association between lower genital tract inflammation and objectively diagnosed endometritis. We analyzed the first 157 patients enrolled in the PEACH study, a multicenter randomized clinical trial designed to compare the effectiveness of outpatient and inpatient therapy for PID. Women less than 38 years of age, who presented with a history of pelvic discomfort for 30 days or less and who were found to have pelvic organ tenderness (uterine or adnexal tenderness) on bimanual examination, were initially invited to participate. After recruitment of the first 58 patients (group 1) we added the presence of leukorrhea, mucopurulent cervicitis, or untreated positive test for N. gonorrhoeae or C. trachomatis to the inclusion criteria (group 2, N = 99). We compared rates of endometritis in the two groups and calculated the sensitivity, specificity, and predicted values of the presence of white blood cells in the vaginal wet preparation. The rate of upper genital tract infection in group 1 was 46.5% (27/58) compared to 49.5% (49/99) in group 2. Microbiologic evidence of either N. gonorrhoeae or C. trachomatis increased from 22.4% in group 1 to 38.3% in group 2. The presence of vaginal white blood cells or mucopus has a high sensitivity (88.9%), but a low specificity (19.4%) for the diagnosis of upper genital-tract infection. Assessment of the lower genital tract for evidence of infection or inflammation is a valuable component of the diagnostic evaluation of pelvic inflammatory disease. The presence of either mucopus or vaginal white blood cells is a highly sensitive test for endometritis in patients with pelvic pain and tenderness.

Risk factors for laparoscopically confirmed pelvic inflammatory disease: findings from Mumbai (Bombay), India

OBJECTIVES

Sexually transmitted diseases (STDs) are an important cause of pelvic inflammatory disease (PID) but have often not been detected in microbiological studies of Indian women admitted to hospital gynaecology wards or private clinics. In this cross sectional study, women living in the inner city of Mumbai (Bombay) were investigated for socioeconomic, clinical, and microbiological risk factors for PID.

METHODS

Microbiological tests and laparoscopic examination were carried out on 2736 women aged < or = 35 years who came to a health facility with suspected acute salpingitis or infertility or for laparoscopic sterilisation. 86 women with a clinical diagnosis of PID were not referred for laparoscopy although their characteristics are described. Associations between various risk factors and PID status were investigated and logistic regression performed on all factors that remained significant.

RESULTS

Of women with a laparoscopically confirmed evaluation, 26 women had acute and 48 chronic pelvic infection. Independent risk factors for PID were later age at menarche (> or = 14 years), a history of stillbirth and no previous pregnancy, history of tuberculosis, STD, dilatation and curettage or previous laparoscopy, and presence of Gardnerella vaginalis.

CONCLUSIONS

It is concluded that STD related risk factors applied to only a small proportion of PID cases and that other determinants of PID are important, including obstetric complications, invasive surgical procedures such as laparoscopy, and tuberculosis.

Managing sexually transmitted diseases in adolescents

Control of sexually transmitted diseases (STDs) in adolescents is a primary responsibility of health care providers. Using the tools of history and physical examination, and drawing on the awareness of different stages of adolescent development, health care providers can define at-risk for STDs. This article discusses screening practices, disease control through reporting and preventive counseling, and treatment guidelines for common STD syndromes.

The pediatrician and the sexually active adolescent. A primer for sexually transmitted diseases

Sexual activity is a common practice among young adolescents, placing them at high risk for STDs, many of which have long-term consequences. Early diagnosis and treatment are essential to limit both the consequences and the spread of these infections. The clinician has a responsibility to the adolescent patient to recognize and treat these diseases. Using history and physical examination, the clinician should be able to determine an adolescent's risk for an STD, and, based on this risk, undertake the appropriate evaluations. Patient treatment, follow-up, and management of sex partners are then guided by the results of either presumptive or definitive diagnostic tests.