Endometritis
Uterine infection is uncommon unless the barrier to ascending infection (acid vaginal pH and cervical mucus) is broken, eg after abortion and childbirth, IUCD insertion, or surgery. Infection may involve Fallopian tubes and ovaries.
Presentation
Lower abdominal pain and fever; uterine tenderness on bimanual palpation. Low-grade infection is often due to chlamydia.
Tests
Do cervical swabs and blood cultures.
Treatment
Give antibiotics (eg doxycyline 100mg/12h PO with metronidazole 500mg/8h PO, eg for 7 days).
Endometrial proliferation
Oestrogen stimulates endometrial proliferation in the first half of the menstrual cycle; it is then influenced by progesterone and is shed at menstruation. A particularly exuberant proliferation is associated with heavy menstrual bleeding and polyps.
Continuous high oestrogen levels (eg anovulatory cycles) make the endometrium hyperplastic (cystic glandular hyperplasia' ”a histological diagnosis after D&C). It eventually breaks down, causing irregular bleeding (dysfunctional uterine bleeding).
Treatment
Cyclical progestogens (p 253).
In older women proliferation may contain foci of atypical cells which may lead to endometrial carcinoma (p 278).
Pyometra
This is a uterus distended by pus eg associated with salpingitis or secondary to outflow blockage.
Treatment
Drain the uterus, treat the cause.
Haematometra
This is a uterus filled with blood due to outflow obstruction. It is rare. The blockage may be an imperforate hymen in the young (p 246); carcinoma; or iatrogenic cervical stenosis, eg after cone biopsy.
Endometrial tuberculosis
Genital tract tuberculosis is rare in Britain, except among high-risk groups (eg immigrants). It is blood-borne and usually affects first the Fallopian tubes, then the endometrium.
It may present with acute salpingitis if disease is very active, or with infertility, pelvic pain, and menstrual disorders (40%) eg amenorrhoea, oligomenorrhoea. There may be pyosalpinx. Exclude lung disease by CXR.
Treatment is medical with antituberculous therapy (OHCM p 564 “7). Repeat endometrial histology after one year. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is treatment of choice if there are adnexal masses and the woman is >40yrs.1
Uterine ultrasound2
Transvaginal ultrasound gives better resolution than transabdominal (as the probe is closer to the target and a higher frequency transducer can be used). Homogeneity, echoes of low intensity and presence of a linear central shadow are associated with absence of endometrial abnormality. Endometrial carcinoma is suggested by endometrial thickness >20mm (>5mm if postmenopausal not on hormones), heterogeneous appearance, and hypoechoic areas. Polyps have cystic appearance (also with hyperechoic endometrium).
If postmenopausal and not on HRT, double-layer endometrial thickness should be <5mm (if perimenopausal <5mm on day 5 of cycle). Sequential hormone replacement †‘endometrial thickness (average 5 “8.5mm); if on continuous combined replacement HRT thicknesses are ~4.5 “7mm; tibolone treated endometrium <5mm; but tamoxifen thickens it to ~13mm. It thins down by 6 months after stopping tamoxifen, then stays thin.22
Ultrasound is useful for detecting fibroids; and assessing cystic change in rapidly growing fibroids to assess risk of malignant change.
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