252 EDITORIAL Sex Transm Infect: first published as 10.1136/sti.2004.009548 on 4 August 2004. Downloaded from ENDOMETRITIS does appear to increase the risk of ....................................................................................... endometritis being asymptomatic.7 One of the few features that has been linked to endometritis is the phase of What is endometritis and does it the menstrual cycle.68 In women pre- senting with lower abdominal pain, in require treatment? whom a diagnosis of PID is being queried, almost 80% have endometritis J D C Ross when they present in the first 3 weeks of the menstrual cycle, compared to ................................................................................... around 20% if they present in the final week of their cycle, just before men- The answer is not straightforward struation.8 This suggests that women are at highest risk of infection ascending he concept of lower genital tract serious effects on future fertility. This and causing endometrial inflammation infection with chlamydia or gonor- limits the clinical applicability of this just following their period, possibly Trhoea causing cervicitis and vaginal approach for making a diagnosis, as because of loss of the cervical mucous discharge is familiar to most sexual does the theoretical risk of introducing plug or hormonal changes affecting health physicians. Likewise, upper geni- infection into the upper genital tract local immune function. It also raises tal tract infection with inflammation of when taking the endometrial biopsy.2 the possibility that endometritis may, at the fallopian tubes and adnexae in the A more rapid assessment of endome- least in a subgroup of women, be a form of pelvic inflammatory disease trial inflammation can be obtained by transient phenomenon with sponta- (PID) is also a common clinical syn- looking at a Gram stained smear or wet neous clearance occurring within a few drome with well recognised implications mount of vaginal discharge. Increasing weeks. for future fertility. It is assumed that numbers of polymorphs in the discharge Vaginal douching has been linked most PID develops secondary to the are associated with endometritis, with a higher incidence of endometritis, spread of infection from the lower although the correlation is not particu- but only in those women who have genital tract, through the uterine cavity larly strong.3 The main purpose of douched recently or give a history of into the upper genital tract. What is less looking for pus cells in vaginal secre- frequent douching.9 It has been postu- certain, and where no clear guidance is tions lies more in excluding PID than lated that douching ‘‘washes away’’ the currently available, is whether this diagnosing it—the negative predictive normal vaginal flora, increasing the intermediate step of endometritis is a value of such an approach is around risk of bacterial vaginosis, which in distinct clinical condition in its own 95%, compared to positive predictive turn predisposes to endometritis. right and, if so, how it should be value of only around 20%. In other Interestingly, the association between diagnosed and treated. words the absence of pus cells makes douching and endometritis is only seen Endometritis is a pathological diag- endometritis (and PID) very unlikely, in those who do not have bacterial nosis with infiltration of the normal but their presence lacks specificity. vaginosis, which is somewhat against vascular architecture by inflammatory Other features on the vaginal smear this theory.9 This highlights the difficul- cells. Agreeing a precise histological such as reduced numbers of lactobacilli, ties of interpreting the relation between definition of endometritis is difficult may also support the diagnosis of upper genital tract infection and douch- http://sti.bmj.com/ since a variety of different features are endometritis but have not been rigor- ing since, until recently, the studies seen—the inflammatory infiltrate may ously assessed. have all been retrospective and therefore be confined to the surface epithelium or unable to attribute cause and effect. spread more deeply into the stroma; More recently, prospective data have One of the central questions in the inflammatory cells may comprise neu- been presented suggesting that women management of endometritis is trophils and/or plasma cells; and who douche are at no higher risk of whether endometritis and PID are lymphoid aggregates or subepithelial upper genital tract infection than those on September 26, 2021 by guest. Protected copyright. haemorrhages have also been reported. different aspects of the same dis- who do not (ISSTDR Meeting Ottawa, The features which correlate most ease, or separate clinical entities 2003, oral presentation 0052). It there- closely to ‘‘true’’ PID are the presence requiring different treatment and fore seems possible that PID itself may of both neutrophils and plasma cells, having a different prognosis make women more likely to douche leading to the most commonly accepted (rather than vice versa), with women definition of endometritis which is five Endometritis is commonly found in using douching to try to reduce the or more neutrophils per 400 power field women who have otherwise uncompli- symptoms (vaginal odour, discharge) in the superficial endometrium, in addi- cated lower genital tract infection. associated with their PID.10 tion to one or more plasma cells per 120 Around a quarter of women with One of the central questions that power field in the endometrial stroma.1 cervical gonorrhoea or chlamydia will needs to be addressed in determining Sampling of the endometrium is also have endometritis on endometrial the correct management of endometritis usually performed using a endometrial biopsy, as do 15% of women with is whether endometritis and PID are suction biopsy device, which is inserted bacterial vaginosis.4 Predicting which different aspects of the same disease, or through the cervix to obtain a small women will have endometritis as separate clinical entities requiring dif- piece of endometrial tissue. This is opposed to infection limited to the lower ferent treatment and having a different generally a simple, well tolerated proce- genital tract is difficult. The presence of prognosis. Endometritis is associated dure performed in an outpatient setting. endometritis is not associated with with abdominal pain6 and also with Unfortunately the fixing, staining, and behavioural or demographic features vaginal discharge, cervical tenderness, reporting of the endometrial sample such as age, ethnicity, condom use, or and pyrexia, albeit at a lower rate than takes several days and even small delays sex during menstruation.5 The use of the is seen with salpingitis.8 Endometritis in confirming the diagnosis and starting oral contraceptive pill does not itself also leads to elevations in the peripheral therapy for pelvic infection can have increase the risk of endometritis,6 but it white blood count and erythrocyte www.stijournal.com EDITORIAL 253 Sex Transm Infect: first published as 10.1136/sti.2004.009548 on 4 August 2004. Downloaded from sedimentation rate, which suggests that women with asymptomatic lower geni- 3 Yudin MH, Hillier SL, Wiesenfeld HC, et al. Vaginal polymorphonuclear leukocytes it is of clinical relevance. The presence of tal tract infections. It is often associated and bacterial vaginosis as markers for endometritis on endometrial biopsy cor- with salpingitis but can cause abdom- histologic endometritis among women relates well, although not completely, inal pain and systemic signs of infection without symptoms of pelvic inflammatory disease. Am J Obstet Gynecol with salpingitis—its positive and nega- even in the absence of classic PID. Some 2003;188:318–23. tive predictive values are around 90%.1 reassurance regarding the long term 4 Wiesenfeld HC, Hillier SL, Krohn MA, et al. Lower Thus, endometritis is commonly asso- sequelae of symptomatic endometritis genital tract infection and endometritis: insight is provided by the PEACH study which into subclinical pelvic inflammatory disease. ciated with salpingitis but either can Obstet Gynecol 2002;100:456–63. occur in isolation. suggests that failure to clear endome- 5 Korn AP, Hessol NA, Padian NS, et al. Risk Does endometritis require treatment? tritis following antibiotic therapy is not factors for plasma cell endometritis among associated with an increased risk of long women with cervical Neisseria gonorrhoeae, Antimicrobial therapy of endometritis cervical Chlamydia trachomatis, or bacterial has been assessed most thoroughly in term sequelae. Endometritis can be a vaginosis. Am J Obstet Gynecol the PEACH study.11 This large rando- distinct clinical syndrome requiring 1998;178:987–90. treatment in those women who are 6 Nelson DB, Ness RB, Peipert JF, et al. mised controlled trial primarily com- Factors predicting upper genital tract pared the efficacy of PID treatment in symptomatic, but evidence for or inflammation among women with lower symptomatic inpatients and outpatients, against active screening and treatment genital tract infection. J Women’s Health of asymptomatic women in the absence 1998;7:1033–40. but also includes data from endometrial 7 Ness RB, Keder LM, Soper DE, et al. Oral biopsies taken at baseline and after of lower genital tract infection is cur- contraception and the recognition of endometritis. 30 days in a subset of patients. Almost rently lacking. Am J Obstet Gynecol 1997;176:580–5. 8 Eckert LO, Hawes SE, Wolner-Hanssen