Chronic endometritis symptoms and treatment in women. Chronic endometritis: the importance of proper treatment of pathology and the likelihood of pregnancy

Inflammatory process in the inner mucous layer of the uterus - the endometrium. Often combined with inflammation of the muscular layer of the uterus - endomyometritis. The endometrium is the inner functional lining of the uterus, which changes its structure over time. menstrual cycle. Each cycle, it grows and matures anew, preparing for the attachment of a fertilized egg, and is rejected if pregnancy does not occur. Normally, the uterine cavity, lined with the endometrium, is reliably protected from infection. But under certain conditions, infectious pathogens easily enter the uterus and cause an inflammatory reaction of its inner layer - endometritis.

General information

Inflammatory process in the inner mucous layer of the uterus - the endometrium. Often combined with inflammation of the muscular layer of the uterus - endomyometritis. The endometrium is the inner functional lining of the uterus that changes its structure throughout the menstrual cycle. Each cycle, it grows and matures anew, preparing for the attachment of a fertilized egg, and is rejected if pregnancy does not occur. Normally, the uterine cavity, lined with the endometrium, is reliably protected from infection. But under certain conditions, infectious pathogens easily enter the uterus and cause an inflammatory reaction of its inner layer - endometritis. According to the nature of the course, acute and chronic forms of endometritis are distinguished.

Acute endometritis

The onset of acute endometritis is often preceded by childbirth, abortion or mini-abortion, diagnostic curettage of the uterine cavity, hysteroscopy and other intrauterine manipulations. Incomplete removal of the remnants of the fetal egg, placenta, accumulation of liquid blood and clots favor the development of infection and acute inflammation of the inner surface of the uterus. The most common manifestation of postpartum infection is postpartum endometritis. It occurs in 4%-20% of cases after natural delivery and in 40% after caesarean section. This is due to hormonal and immune changes in the body of a pregnant woman, a decrease in overall immunity and resistance to infections.

In the development of endometritis, the state of the immune, endocrine, nervous systems often aggravating the course of the disease. With the nonspecific nature of endometritis, the pathogenic flora in the uterus is not detected. A non-specific form of endometritis can be caused by bacterial vaginosis, HIV infection, the presence of an intrauterine device, and the use of hormonal contraceptives.

Chronic endometritis

The chronic form of endometritis is often a consequence of untreated acute endometritis that occurs after childbirth, abortion, intrauterine manipulations, due to the presence of foreign bodies in the uterus. In 80-90% of cases, chronic endometritis occurs among women of the reproductive period and tends to increase, which is explained by the widespread use of intrauterine contraception, an increase in the number of abortions, intrauterine diagnostic and medical procedures. Chronic endometritis is among the most common causes infertility, miscarriages, failed in vitro fertilization attempts, complicated pregnancies, childbirth and the postpartum period.

High-precision immunocytochemical diagnostics is used to identify an infectious agent in chronic endometritis. The chronic form of endometritis often has an erased clinical course without pronounced signs of microbial infection. There is a thickening of the uterine mucosa, serous plaque, hemorrhages, fibrous adhesions, leading to disruption of the normal functioning of the endometrium.

Symptoms of acute endometritis

Acute endometritis usually develops 3-4 days after infection and is manifested by fever, pain in the lower abdomen, discharge from the genital tract with an unpleasant odor, painful urination, increased heart rate, and chills. Especially severe and rapid course are acute endometritis in patients with intrauterine devices. Therefore, the very first signs of acute endometritis are the reason for the immediate consultation of a gynecologist.

• using vaginal tampons

absorbing bloody issues, tampons are the optimal environment for the development of infection. Tampons should be changed every 4-6 hours, do not use them at night, before or after your period, in hot climates. Violation of the rules for using tampons can lead to the development of toxic shock syndrome.

• chronic stress, overwork and poor hygiene.

These factors weaken the body and make it at risk of infection.

Diagnosis of endometritis

Diagnosis of acute endometritis is based on the collection of an anamnesis of the disease, patient complaints, symptoms, gynecological examination, clinical analysis blood and bacterioscopic examination of smears. Women with an acute form of endometritis are treated inpatiently, because there is a potential risk of developing severe septic complications (parametritis, pelvioperitonitis, peritonitis).

In the diagnosis of the chronic form of endometritis, in addition to clarifying the clinical symptoms and anamnesis of the disease, a special role belongs to the curettage of the uterine mucosa for diagnostic purposes. Histological examination of the altered endometrium allows confirming the diagnosis of chronic endometritis. Important diagnostic methods are ultrasound (ultrasound) and endoscopic (hysteroscopy) studies that allow to identify structural changes in the endometrium.

Treatment of acute endometritis

In the acute phase of endometritis, patients are shown treatment in a hospital with bed rest, mental and physical rest, an easily digestible full-fledged diet, and a drinking regimen. basis drug treatment acute endometritis is antibiotic therapy, taking into account the sensitivity of the pathogen (amoxicillin, ampicillin, clindamycin, gentamicin, kanamycin, lincomycin, etc.). With a mixed microbial flora, a combination of several antibiotics is indicated. Due to the frequent attachment of anaerobic pathogens, metronidazole is included in the treatment regimen for acute endometritis.

In order to relieve intoxication, it is indicated intravenous administration salt and protein solutions up to 2-2.5 liters per day. It is advisable to include multivitamins in the treatment regimen for acute endometritis, antihistamines, immunomodulators, probiotics, antifungal agents. With analgesic, anti-inflammatory and hemostatic purposes, cold is applied to the abdomen (2 hours - cold, 30 minutes - break). When subsiding acute symptoms physiotherapy, hirudotherapy ( medicinal leeches).

Treatment of chronic endometritis

In the treatment of chronic endometritis, modern gynecology uses an integrated approach, including antimicrobial, immunomodulatory, restorative, physiotherapeutic treatment. Treatment is carried out in stages. The first step is the elimination of infectious agents, followed by a course aimed at restoring the endometrium. Broad-spectrum antibiotics (sparfloxacin, doxycycline, etc.) are usually used. The recovery course is based on a combination of hormonal (estradiol plus progesterone) and metabolic therapy (hemoderivate of calf blood, inosine, ascorbic acid, vitamin E).

Drugs can be injected directly into the uterine mucosa, which creates their increased concentration directly in the focus of inflammation and provides a high healing effect. Cupping uterine bleeding is carried out by the appointment of hormones or a solution of aminocaproic acid (intravenously or intrauterine). An important place in the treatment of chronic endometritis is given to physiotherapy: UHF, electrophoresis of copper, zinc, lidase, iodine, pulsed ultrasound therapy, magnetotherapy. Physiotherapy treatment reduces inflammatory edema of the endometrium, activates blood circulation, stimulates immunological reactions. Patients with chronic endometritis are shown balneotherapy (mud therapy, hydrotherapy).

The effectiveness of the treatment of chronic endometritis is evaluated according to the following criteria:

• restoration of the morphological structure of the endometrium (according to the results of ultrasound)
• restoration of the menstrual cycle.
• elimination of infection
• disappearance of pathological symptoms (pain, bleeding)
• restoration of childbearing function

Complications and prevention of endometritis

The endometrium is an important functional layer of the uterus, responsible for ensuring the normal course of pregnancy. Inflammatory diseases of the endometrium - endometritis - entail a complicated course of pregnancy: the threat of miscarriage, placental insufficiency, postpartum hemorrhage. Therefore, the management of pregnancy in a woman with endometritis should be carried out with increased attention.

Long-term consequences of endometritis are adhesions inside the uterus (intrauterine synechia), sclerosis of the uterine cavity, disrupted menstrual cycle, endometrial polyps and cysts. With endometritis, the ovaries and tubes may be involved in the inflammatory process, peritonitis, adhesions of the intestine and pelvic organs (adhesive disease) may develop. Adhesive disease is manifested by pain and often leads to infertility.

To avoid the occurrence of endometritis, it is necessary to prevent abortions, observe hygiene measures, especially during the menstrual period, prevent postpartum and post-abortion infections, use barrier contraception (condoms) to prevent sexually transmitted infections. Timely detection of asymptomatic infections and their treatment in most cases gives a favorable prognosis for subsequent pregnancies and childbirth.

Galina Alekseevna asks:

Can chronic endometritis be cured?

The choice of antibiotics in the treatment of this disease is a complex process. It is most rational to be guided by the data obtained by growing bacteria on special media, which can show the sensitivity of pathogens. Otherwise, the attending physician prescribes antibiotics depending on the suspected pathogen. Maximum efficiency is observed with the intrauterine administration of antimicrobial drugs, when the medicinal substances completely reach the infectious foci.

Symptomatic remedies.

As a symptomatic therapy, use:

• desensitizing agents;
• sedatives;
• painkillers.

Surgery.

To accelerate the recovery of the endometrium and improve menstrual and reproductive function, spa treatment is often recommended. With timely and adequate treatment, the prognosis for this disease quite favorable.

• • Uterine bleeding (intermenstrual)

Endometritis is an inflammatory disease of the inner surface of the uterus.

The main generally accepted classification divides endometritis into acute and chronic.

Overview of Acute Endometritis

Acute endometritis most often occurs after abortion, childbirth (postpartum endometritis), or diagnostic curettage of the uterus. The presence of blood, remnants of decidual tissue, fetal egg contributes to the growth of microbial flora, characterized by diversity.

There is an increase in the role of chlamydial and genital herpetic infections.

According to the etiological principle, all endometritis divided into specific and non-specific.

Specific include tuberculous, gonorrheal endometritis, as well as damage to the mucous membrane of the uterus by actinomycosis.

In turn, bacterial endometritis is subdivided by them into tuberculous, gonorrheal, chlamydial and actinomycosis of the mucous membrane of the uterine body.

An important role is played by the state of the immune, nervous, endocrine and other body systems that contribute to the development of low-symptomatic, erased forms of inflammatory processes.

Treatment

As a rule, the treatment of endometritis is carried out in a hospital and only under the supervision of a physician. Self-medication can lead to further dissemination infection, cause infertility. In cases where the cause of endometritis is the remains of the fetal egg after an unsuccessful abortion or parts of the placenta after childbirth, these elements are removed and the uterus is washed with aseptic solutions.

Since the main cause of the development of the disease is a microbial infection, the treatment complex necessarily includes antibiotics, in accordance with the sensitivity of the pathogen to them, or broad-spectrum antibiotics.

Usually, various combinations of drugs are used, for example metronidazole (Metrogil) intravenously and gentamicin intramuscularly. This helps to achieve greater efficiency in the case when the disease is caused by several types of microorganisms.

Successfully used in the treatment of severe endometritis and third-generation cephalosporins: ceftazidime, ceftriaxone, cefoperazone, etc., as well as imipenem / cilastatin and meropenem, which have an ultra-wide spectrum of antimicrobial action. Due to their high efficacy and low toxicity, these drugs help to replace combinations of several antibiotics. The duration of therapy is determined by the severity of the patient's condition and continues until complete victory over the causative agent of the disease.

In addition to antibacterial drugs, if necessary, a complex of other therapeutic measures is prescribed: painkillers, antispasmodic and hemostatic drugs, intravenous drip of solutions that accelerate the elimination of toxins from the body.

In the treatment of endometritis, it is very important to increase the body's resistance. Prescribe vitamins, drugs that normalize cellular metabolism, increase immunity - interferon drugs (kipferon or viferon), as well as injections of normal human immunoglobulin.

One of the leading places in complex therapy belongs to procedures that promote the activation of blood circulation in the pelvic organs, stimulating their function. Magnetotherapy, pulsed ultrasound, electrophoresis with iodine and zinc, UHF heating, mud therapy, paraffin and ozocerite applications on the lower abdomen are used.

After a course of anti-inflammatory therapy, it is recommended to take oral contraceptives for several months. They have antioxidant and anti-inflammatory properties and help to normalize the menstrual cycle. In addition, a woman avoids an unwanted pregnancy, and therefore an abortion, which can lead to an aggravation of the process.

In most cases timely treatment leads to good results, which avoids complications of pregnancy and childbirth.

Prevention

Prevention of endometritis in women at high risk of developing the disease (for example, after a caesarean section) includes taking antibacterial drugs.

Prevention, after treatment, is based on the observance of sterility during uterine manipulations, childbirth, abortion, hygiene of sexual life. Regular follow-up with a gynecologist is essential preventive examinations at least 2 times a year) in order to timely detect inflammatory infections. It is important to strengthen the immune system.

On our website you will find everything you wanted to know about the treatment of endometrial hyperplasia.

Chronic endometritis

The frequency of chronic endometritis varies widely - from 0.2 to 67%, averaging 14%. AT last years there is a trend towards an increase in the frequency of chronic endometritis, which may be due to the widespread use of intrauterine contraceptives, an increase in the number of abortions and various intrauterine manipulations, including endoscopic research methods.

As a rule, chronic endometritis occurs as a result of acute postpartum or post-abortion endometritis that has not been fully cured, often repeated intrauterine interventions due to uterine bleeding contribute to its development. Rarely, the cause of chronic endometritis may be the remaining parts of the bones after the interruption of long periods of pregnancy or suture material after a caesarean section. However, the occurrence of chronic endometritis and without acute stage inflammation.

If the role of the microbial factor in acute endometritis is obvious, then the question of its role in maintaining the chronicity of the inflammatory process remains undefined. Often the course of chronic inflammatory diseases may be aggravated by the manifestation of dysbacteriosis due to negative side effects drugs and superinfection (autoinfection with opportunistic microbes).

Most chronic endometritis proceeds latently and does not have clinical manifestations infections. When using conventional bacteriological methods, it is not always possible to identify an infectious agent. To detect it, it is necessary to use a more subtle immunocytochemical method.

In chronic endometritis, there are usually no specific macroscopic changes in the endometrium. Serous, hemorrhagic or purulent discharge may be observed on its surface. The endometrium may be thickened and produce abundant material when the walls of the uterine cavity are scraped. Fibrous adhesions are rare, which can be the cause of its partial obliteration and infertility. In such cases, when scraping the walls of the uterine cavity, little material is obtained.

The conditions that violate the barrier mechanisms of protection against the penetration of infection into the genital tract and cause the development of the inflammatory process include:

Birth injuries of the perineum, causing the gaping of the genital slit and contributing to the unimpeded penetration of pathogenic microorganisms from the external genital organs into the vagina.

Prolapse of the walls of the vagina.

Mechanical, chemical, thermal factors that have a damaging effect on the epithelium of the vaginal mucosa. These include violation of hygiene rules, frequent douching, the introduction of chemical contraceptives into the vagina, etc. In this case, increased desquamation of the surface layer of the epithelium or dystrophic changes in him. In such cases, the amount of glycogen necessary for the life of Dederlein sticks decreases, the acidity of the vaginal contents decreases, and the formation of secretory immunity factors is disrupted.

Ruptures of the cervix, causing the gaping of the external pharynx or the occurrence of ectropion, while the bactericidal properties of cervical mucus are violated. Isthmic-cervical insufficiency (organic or traumatic) has the same value.

Childbirth, abortion, menstruation. In this case, the cervical mucus, the contents of the vagina are washed out with blood, along with immune defense factors and lactic acid bacteria, and the vagina becomes alkalized. Microorganisms that freely penetrate into the uterus find optimal conditions for their vital activity on a vast wound surface.

An aggravating effect is the use of disinfectants during childbirth and abortion, which completely destroy the saprophytic autoflora of the vagina and create favorable conditions for the introduction of pathogenic microorganisms.

Intrauterine contraceptives. There is evidence of a violation of the bactericidal properties of cervical mucus, while the infection penetrates into the cervical canal and the uterine cavity through the threads of intrauterine devices.

The use of tampons like "Tampax". By adsorbing blood, they create optimal conditions for the rapid reproduction of pathogenic microorganisms and inhibition of the protective mechanisms of the vagina. Especially dangerous is the use of these tampons in countries with a hot climate, where in some cases it leads to the development of fulminant sepsis.

Symptoms of endometritis

Clinical signs of acute endometritis appear, as a rule, on the 3-4th day after infection.

• The temperature rises, the pulse quickens, chilling, leukocytosis is detected in the blood, a shift leukocyte formula to the left, ESR acceleration.
• The uterus is moderately enlarged, sensitive to palpation, especially on the sides (along the large lymphatic vessels).
• The discharge is serous-purulent, often long time they are sacrilegious.

The acute stage of endometritis lasts 8-10 days, with proper treatment, the process ends, less often it turns into a subacute and chronic form.

Endometritis can be mild or abortive, especially when antibiotics are used.

Symptoms of chronic endometritis

The clinical picture of chronic endometritis largely reflects the depth and duration of changes in the uterine mucosa.

The main symptom of the disease is uterine bleeding. Median (intermenstrual) spotting is associated with an increase in the permeability of the endometrial vessels during the period of ovulation. Such vascular changes are observed in healthy women, but diapedesis of blood cells is not clinically noticeable. The reasons for uterine bleeding include a decrease in the contractile activity of the uterus and a violation of the aggregation properties of platelets.

In addition to bleeding, this contingent of patients often has a change in secretory function in the form of serous or serous-purulent discharge from the genital tract.

Less bright, but rather constant, are complaints of aching pains in the lower abdomen, a slight increase and induration of the uterus, which is detected during a bimanual examination.

Chronic endometritis does not prevent conception, which occurs in the presence of ovulation. In combination with concomitant ovarian dysfunction or other genital diseases, chronic endometritis causes reproductive dysfunction - infertility and spontaneous miscarriages, including habitual

Diagnosis of endometritis

The diagnosis of acute endometritis is made on the basis of patient complaints, clinical picture diseases, general and gynecological examination, laboratory examination data.

The echographic method is not informative enough in the diagnosis of acute endometritis, its results are evaluated only in combination with clinical, anamnestic and clinical and laboratory data of the study.

A patient with acute endometritis should be treated in a hospital (!), because with untimely help or with insufficient treatment of endometritis, a woman may develop severe complications, such as peritonitis, which can lead to a sad outcome.

Diagnosis of chronic endometritis

Diagnosis of chronic endometritis is based on the clinical manifestations of the disease, anamnesis with the final confirmation of the diagnosis by histological examination endometrial scraping. To obtain maximum information, the operation of diagnostic curettage of the uterine mucosa is recommended to be carried out in the first phase (8-10th day) of the menstrual cycle.

In recent years, hysteroscopy has been used to diagnose chronic endometritis.

To clarify the diagnosis, it is important to conduct an ultrasound examination. The most common echographic sign of endometritis is a change in the structure of the endometrium (the appearance in the zone of the median M-echo of an area of ​​increased echogenicity of various sizes and shapes). Quite often, the presence of gas is detected in the uterine cavity, in the basal layer of the endometrium, small (0.1-0.2 cm in diameter) clear hyperechoic formations are determined, which are areas of fibrosis, sclerosis and calcification. The expansion of the uterine cavity by up to 0.3-0.7 cm due to the liquid content is noted in 30% of patients.

Treatment of acute endometritis

The main place in the treatment of acute endometritis belongs to antibiotics, the effectiveness of which is determined by the properties of the pathogen and its sensitivity to antibiotics. It is very important that the applied dose of antimicrobial drugs ensures their maximum concentration in the focus of inflammation. Antibiotics with the longest half-life should be used; for example, the half-life of amoxicillin is 8 hours, ampicillin is 5 hours, bacampicillin is 5 hours. clinical course process and the risk of its generalization, with a combination of gram-negative and gram-positive flora, with suspicion of anaerobic flora, it is necessary to use different combinations of antibiotics. A combination of clindamycin with chloramphenicol is recommended; gentamicin with levomycetin, lincomycin or clindamycin.

If an association of microbes (streptococci, staphylococci, enterobacteria) and anaerobes (bacteroids, peptococci, peptostreptococci) is detected in patients with acute endometritis, it is recommended to start treatment with the appointment of penicillin at 20000000 - 30000000 IU / m, simultaneously prescribe aminoglycosides (kanamycin 0.5 g / m 2 times a day or gentamicin - 1 mg/kg IM 3 times a day). With absence clinical effect within 72 hours, clindamycin 600 mg is added to the ongoing therapy. in / in 4 times a day until a positive clinical dynamics is obtained. After that, penicillin and aminoglycosides are used for 5 days, using drugs for oral administration.

If anaerobic flora is suspected, metronidazole is used. In severe cases, metronidazole is prescribed intravenously at a daily dose of 1-1.5 g at a rate of 5 ml / min. within 5-8 days; recommended in less severe cases oral administration drug at a dose of 400-500 mg. 3 times a day for 7-8 days, if indicated, the duration of administration can be increased.

With pronounced signs of intoxication, infusion therapy is used: parenteral administration of a 5% glucose solution, polyglucin, rheopolyglucin, gemodez, protein preparations (total amount of fluid 2-2.5 l / day). If necessary, the composition of the infusion medium includes vitamins, agents that correct the acid-base state (4-5% sodium bicarbonate solution - 500-1000 ml.). The use of antihistamines (diphenhydramine, suprastin) is shown.

The physical methods of treatment include a long-used method - cold on the suprapubic region. Cold, acting on the receptors of this area of ​​the skin, has an analgesic, anti-inflammatory and hemostatic effect. Cold is applied intermittently (after 2 hours of use, take a break for half an hour).

Treatment of chronic endometritis

Used for chronic endometritis complex treatment, including drugs aimed at the treatment of concomitant diseases, restorative drugs, according to indications - sedatives, desensitizing drugs, vitamins. The leading role is played by physiotherapy, which improves the hemodynamics of the small pelvis, stimulates the reduced function of the ovaries and the activity of endometrial receptors.

Antibiotics can be used when signs of exacerbation of endometritis appear, including those that occur in response to physiotherapy procedures. During remission, the appointment of antibiotics and sulfa drugs is unreasonable.

High therapeutic effect achieved with the introduction of drugs, including antibiotics, directly into the uterine mucosa. The method ensures the creation of a high concentration of medicinal substances in the focus of chronic inflammation.

In order to eliminate uterine bleeding, the complex of measures, in addition to hormonal hemostasis, includes a solution of γ-aminocaproic acid. The solution is injected into the uterine cavity daily, 3-5 ml. within 5-7 days.

Physiotherapy takes the main place in the treatment of chronic endometritis; it is carried out differentially, taking into account the duration of the process, the patient's age, ovarian function.

With unimpaired ovarian function and a short illness (less than 2 years), the use of microwaves in the centimeter range or UHF magnetic field is indicated; if the process lasts more than 2 years, pulsed ultrasound or zinc electrophoresis is recommended.

With hypofunction of the ovaries and the duration of the endometrium for more than 2 years, microwaves in the centimeter range are preferred, the use of a magnetic field, UHF is also shown; in the course of the disease for more than 2 years, pulsed ultrasound (preferably) or iodine electrophoresis is recommended. With a combination of chronic endometritis and salpingo-oophoritis, young women are recommended ultrasound in a pulsed mode, patients over 35 years old - combined electrophoresis of iodine and zinc.

Physiotherapy often contributes to the activation of the hormonal function of the ovaries.

Hormonal preparations are recommended in case of insufficient effect of physiotherapy. hormone therapy carried out taking into account the age of the patient, the duration of the disease, concomitant pathological processes, the phase of the menstrual cycle, the degree of ovarian hypofunction (usually there are indications for replacement cyclic therapy: estrogens in the first, progesterone in the second phase).

Spa treatment (peloid therapy, balneotherapy) is effective.

Naturally, simultaneous treatment of the sexual partner is indicated.

Treatment of chronic endometritis is complex and complex therapy aimed at suppressing the symptomatic picture of the disease, eliminating the causes of pathological condition and normalization of the functioning of the uterus.

Endometritis in women occurs due to the entry of an infectious agent into the uterine cavity. Sexually transmitted diseases and mechanical damage to the uterine cavity as a result of medical manipulations can provoke the disease.

What it is - chronic form endometritis? This is a consequence of an untreated disease that occurs in an acute form. In some women, endometritis can be cured without consequences, in others, the pathological process becomes chronic. It's all about the presence of provoking factors that increase the likelihood of the disease degenerating into chronic inactive endometritis:

• multiple abortions in history;
• hysteroscopy;
• performing a biopsy;
• the presence of vaginal bacteriosis;
• candidiasis;

• genital herpes;
• mycoplasmosis;
• venereal diseases;
• the presence of fibroids;
• polyps in the uterine cavity;
• chronic form of cervicitis;
• fibrosis of the stroma of the endometrium;
• sclerosis of the endometrial stroma.

The development of chronic endometritis may be associated with the presence of a uterine spiral in a woman. The contraceptive can injure the uterus and cause sluggish inflammation of the endometrium.

Despite the presence of many reasons that provoke the degeneration of endometritis into a chronic form, in many women the etiology of the disease remains unclear.

The chronic type of endometritis is an autoimmune reaction of the body to the entry of an infectious agent into the uterine cavity. Autoimmune endometritis, if not treated in a timely manner, quickly degenerates into chronic stage which is almost impossible to cure. Symptomatic, supportive therapy is carried out.

Kinds

Depending on the cause of the appearance, the pathology can be specific and nonspecific:

1. Chronic nonspecific endometritis occurs due to trauma to the mucous membrane of the uterine cavity. Acute endometritis of the uterus also provokes the occurrence of pathology, aggravated as a result of the use of vaginal and uterine contraceptives, the transferred procedure for curettage of the uterine cavity, oppressed immune system.
2. The causes of a specific type of disease are the ingress of infectious microflora. In most cases, the cause of this form of the disease is genital herpes, mycoplasmosis, sexually transmitted diseases.

Symptoms

In chronic endometritis, the symptomatic picture is not specific. Symptoms are common to many other gynecological diseases. Chronic endometritis has the following manifestations:

• disturbed menstrual cycle (prolonged absence of menstruation not related to pregnancy);

• profuse bleeding during menstruation, or the reverse picture, when the volume menstrual blood does not exceed 50 ml;
• vaginal discharge in the middle of the cycle;
• pain in the lower abdomen;
• inability to conceive a child.

Symptoms of chronic endometritis are associated in most cases with menstrual irregularities. Pain in the lower abdomen is severe, dull, occurs both during menstruation and after sexual intercourse or intense physical activity.

Exacerbation of chronic endometritis is accompanied by increased pain in the lower abdomen. Vaginal discharge appears, which may be brown or gray, have an unpleasant odor. Due to the total disruption of the structure and functioning of the uterine mucosa with a sluggish course of the disease, a woman cannot become pregnant.

Diagnostics

Since the signs of chronic metroendometritis are nonspecific, indirect signs such as menstrual irregularities and pain in the lower abdomen occur with many diseases. This requires advanced diagnostics.

The gynecologist interviews the woman about the complaints that bother her, collects a thorough history, which takes into account all the gynecological diseases previously suffered by the patient. A woman is examined on a gynecological chair, during which the endometrial stroma, which has an altered structure, is examined.

A smear is taken from the vagina for flora. Analysis of the microflora is carried out on the basis of smears taken from the urethra and cervical canal.

One of the main methods for studying diseases of the genitourinary system is the analysis of PCR - polymerase chain reaction. During this laboratory research the type of pathogenic microflora and its sensitivity to certain antibiotics are revealed. Based on the data obtained, a scheme for the treatment of chronic endometritis is signed.

The most informative diagnostic method is an ultrasound examination of the uterine cavity. The method of implementation is transvaginal. To examine the condition of the blood vessels, ultrasound is performed simultaneously with Doppler ultrasound.

A characteristic echographic sign of chronic endometritis is the heterogeneous structure of the uterine layer. Other signs of endometritis on ultrasound are the development of hyperplasia (cell proliferation), an increase in the thickness of the uterine layer.

Since the risk of endometritis increases in the presence of polyps and tumors, a biopsy is performed . Echo-signs of chronic endometritis are considered in combination with the results of laboratory tests.

Treatment

Treatment of chronic endometritis is complex, carried out in several stages. The combined approach is distinctive feature treatment this disease.

The first stage is the removal of an infectious agent from the uterine cavity. In the treatment of chronic endometritis, antibacterial drugs are used, selected individually, depending on which pathogen caused the development of the disease.

The second stage is the normalization of the state of the immune system. Without taking immunostimulating drugs and immunomodulators (Polyoxidonium), it is very difficult to cure autoimmune endometritis.

The third stage is the treatment and regeneration of the uterine layer of the endometrium. Therapy involves the use of physiotherapy procedures that can heal and restore the integrity of the mucous membrane and normalize its functioning. An appointment is also given hormonal drugs+ COC.

Medicines

Therapy of the chronic form of endometritis with antibiotics:

• preparations of the macrolide group;
• antibiotics - cephalosporins.

drugs are prescribed antifungal action if the disease was a consequence of candidiasis or bacterial vaginosis.

The drug is mandatory Polyoxidonium, aimed at inhibiting pathogenic microflora and reducing the inflammatory process. Polyoxidonium should be taken regularly, it helps to suppress the activity of pathogenic microflora. Method of administration - oral, Polyoxidonium is available in tablet form.

Additional medications:

• Actovegin- helps with moderate hyperplasia, contributes to the fact that soft tissue cells are completely renewed. Actovegin can be administered both in tablets and in injections;
• Duphaston- a hormonal drug that stops signs of hyperplasia, normalizes the state and functioning of the organs of the genitourinary system;
• vitamins;
• antioxidants.

Physiotherapy

To eliminate hyperplasia, relieve the symptomatic picture and speed up recovery, physiotherapy procedures are prescribed:

• interference therapy;
• magnetotherapy;
• iontophoresis (can be carried out with zinc and copper ion);
• plasmapheresis.

If there is purulent discharge douching is prescribed from the vagina. Irrigation of the vagina should be carried out with antiseptic preparations. To fight focal type pathology, douching is prescribed with solutions that stop signs of intoxication and contribute to the fastest recovery of the mucous membrane of the uterine layer.

When treating a disease, a diet is mandatory. Foods that irritate the mucous membranes are excluded from the diet - pickles, marinades, coffee and alcohol, fatty foods.

Can chronic endometritis be cured? folk remedies? No. Various herbal decoctions can only stop the painful symptomatic picture, but they are not able to destroy active pathogens.

If you still want to take folk methods as an additional therapy, you should consult your doctor before treating chronic endometritis with herbs.

Complications and prevention

What is the pathological process of the uterus dangerous? This disease, if not treated, can cause even more development of hyperplasia. Pathogenic microflora spreads to other organs of the genitourinary system, causing a number of infectious inflammatory diseases.

In severe clinical cases, the only treatment will be surgical intervention with partial or complete resection of the uterus and appendages. It is important to understand that it is impossible to constantly take medications alone aimed at stopping the symptomatic picture. Treatment should be complex and long.

Without timely treatment of chronic endometritis, the signs and symptoms of the disease will constantly worsen. In addition to the fact that there will be pathological periods with endometritis, long and plentiful, a woman will not be able to conceive a child, since this disease leads to infertility.

Knowing what chronic endometritis is, you can develop preventive actions for the prevention of this disease. Prevention includes regular examination at the gynecologist, timely treatment of infectious and inflammatory diseases, especially the acute form of pathology. If the disease has managed to degenerate into a chronic form, it is necessary to regularly carry out maintenance therapy.

When examining women with infertility, the diagnosis of endometritis with chronic course is of decisive importance. It belongs to the group of female inflammatory diseases of the pelvic organs (PID) and ranks first among them.

PID occurs in 46-90% (according to various sources) of women of childbearing age ( average age- 36 years). In the total number of causes of chronic pelvic pain syndrome, they account for 24%, ectopic pregnancy - 3%, miscarriage - 45%, infertility - 40%. Chronic inflammatory processes in 40-43% lead to menstrual irregularities, and in 80% - to infertility.

Endometritis - what is it

Endometritis is an inflammation of the mucous membrane of the uterus (endometrium), morphologically consisting of two layers - functional and basal. The first one is turned into the uterine cavity and consists of a single layer of cylindrical epithelial cells. Between them are glandular cells that produce protective mucus, and a large number of small branches of the spiral arteries. During each menstruation, the functional cell layer is destroyed and removed with blood and mucus, after which it is restored again from the cells of the basal layer in the first phase of the menstrual cycle.

Natural defense mechanisms such as anatomical features structures, protective mucus of the uterine cavity and cervical canal containing immunoglobulins and antibodies, acidic environment of the vagina, microbiocinosis of these sections, local immune defense in most cases can prevent the development of infection in the genitals. With their disorder, in this particular case, acute or chronic endometritis develops, the manifestations of which depend on the severity of the inflammation reaction.

Acute endometritis

Most often it is caused by urogenital infection with herpes simplex and Epstein-Barr viruses, mycoplasma and, ureaplasma and cytomegalovirus, coli, streptococci, meningococci, enteroviruses and Trichomonas, Mycobacterium tuberculosis. Less often, the disease is caused by opportunistic pathogens. Usually mixed microflora is found in crops.

Risk factors that create favorable conditions in the uterus for the development and reproduction of an infectious agent include:

• natural childbirth and C-section, as a result of which postpartum endometritis develops in 4-20% and 45%, respectively;
• diagnostic and therapeutic (for bleeding, missed pregnancy) curettage and other diagnostic manipulations, for example, hysteroscopy and hysterosalpingography, probing of the uterine cavity, aspiration biopsy endometrium;
• introduction or removal of the intrauterine device, as well as, against its background, artificial insemination or in vitro fertilization;
• spontaneous or artificial termination of pregnancy, especially instrumental;
• menstruation, infectious processes in the vagina and uterine appendages, as well as in the urinary system, cervical canal and endometrial polyps, uterine fibroids;
• hormonal dysfunctions or taking hormonal drugs (glucocorticoids);
• weakening of general immunity as a result of prolonged or frequent stressful conditions, diabetes and other general chronic diseases;
• transfer of pathogens with blood or lymph from chronic foci of infection (very rare).

The most likely risk factors are listed in the first four paragraphs.

Clinical manifestations

Symptoms of acute endometritis occur 3-4 days after infection. The disease begins acutely, there are:

1. Aching pain and a feeling of heaviness in the lower abdomen.
2. General malaise, fever.
3. Abundant serous or sanious, sometimes with a smell, discharge from the genital tract.
4. Bleeding if endometritis developed after childbirth or abortion.

In case of joining staph infection acute purulent endometritis (pyometra) develops, in which the condition is much more severe due to general intoxication. It is accompanied by chills high temperature, severe cramping pains in the lower abdomen, the appearance of copious serous-purulent and purulent discharge, the development of a septic condition is possible.

Diagnosis of endometritis with an acute course of the process is carried out on the basis of an anamnesis (history of the disease), which allows you to establish a risk factor and partially determine the treatment plan, the clinical course and symptoms of the disease, and gynecological examination data. In addition, there are clinical trial blood and urine, clinical and bacteriological examination of smears from the vagina and cervix, sowing the contents of the genital tract for the sensitivity of pathogenic microflora to antibiotics, if necessary -.

Principles of treatment

Treatment of endometritis (acute non-purulent) consists in the removal of the intrauterine device, followed by curettage of the uterine cavity, in curettage after spontaneous or induced abortion in order to remove the remnants of the fetal egg, after childbirth - in order to remove the placental lobule or remnants of the membranes of the fetus.

After that, antibiotics, anti-inflammatory and antibacterial agents, desensitizing and restorative drugs are prescribed. The main treatment of endometritis with antibiotics is the use of broad-spectrum drugs, as well as in combination with each other and in combination with antibacterial drugs. For example, cephalosporins or broad-spectrum antibiotics are used penicillin series in combination with aminoglycosides, as well as their combination with Metranidazole or Ornidazole.

If anaerobic microflora is found in smears, the addition of Ornidazole or Metranidazole is mandatory, and a mixed infection is additionally carried out by sanitation of the vagina with local agents in the form of gels or suppositories with antimicrobials(Polygynax, Terzhinan), washing with antiseptic solutions (Betadine, Hexicon).

In addition, after reducing the severity of inflammatory processes (lowering temperature), physiotherapeutic procedures are applied - low-intensity ultrasound, magnetotherapy, laser, inductothermy.

In acute purulent endometritis, intravenous therapy is added with solutions that reduce the effects of intoxication and improve the rheological properties of blood, protein solutions. There may be a need for more radical, surgical treatment (supravaginal amputation or extirpation of the uterus).

After acute endometritis, especially purulent, synechia (unions, connective tissue septa) can form in the uterine cavity.

Chronic endometritis

Its prevalence is, according to different authors, 10-85%. Such a wide statistical range is explained by the complexity of diagnosis, as well as clinical and morphological (tissue structure) confirmation.

Currently, the chronic form of endometritis is considered as a clinical and morphological syndrome, in which, as a result of damage to endometrial cells by an infectious agent, functional and structural changes in the endometrium occur. The latter violate its cyclic transformations (detachment and recovery), the receptor reaction of the cells of the mucous membrane of the uterine cavity and its ability to implant a fertilized egg.

Some authors believe that chronic endometritis is not a clinical at all, but a morphological concept, and it is difficult to navigate by clinical symptoms. Very often, women do not come with any complaints of an inflammatory nature, but only about infertility. And only when diagnosing the cause of infertility, the presence of asymptomatic endometritis is revealed.

Autoimmune processes in chronic endometritis

PID has recently been considered as a disease caused by infectious agents and further developed as a pathological, self-supporting autoimmune reaction. An important factor in its development is the insufficiency of the immune system as a result of its maladjustment. The resulting secondary immunodeficiency is the cause of a decrease in the body's resistance to the effects of infectious agents.

Active viruses or bacteria that are antigens and have caused long-term chronic endometritis damage epithelial cells With additional education antigens in the form of destroyed proteins of the endometrium's own tissues (autoantigens).

In addition, the infectious agent disrupts the formation of antibodies, resulting in the accumulation of additional antigens. The local immunocompetent system is activated, aimed at neutralizing antigens. It is overloaded and gradually depleted, the weakened general immune system of the body is included in the process, which already destroys autoantigens and healthy tissues due to the lack of a protein difference between them.

That is, the immune system ceases to distinguish between its destroyed and healthy cells, as a result of which the formed autoimmune mechanism affects the healthy endometrium. Chronic endometritis turns into a self-sustaining inflammatory chronic process - autoimmune endometritis, for the maintenance of which there is no longer a need for an infectious agent. Therefore, often it is not detected during research.

Thus, autoimmune endometritis is not an independent disease, but a later stage of the same chronic endometritis.

Is it possible to get pregnant with endometritis?

The sensitivity of the endometrium and, accordingly, reproductive functions at the initial stage of chronic endometritis are still at a satisfactory level, due to the presence of certain compensatory mechanisms. Their effectiveness largely depends on the presence of a combined pathology of the reproductive organs, the activity of the infectious agent, the adequacy of hormonal regulation, and the activity of the immune system. Therefore, pregnancy in the initial stages of chronic endometritis is quite possible.

Chronic endometritis may develop insidiously on its own, be the result of the risk factors listed in the Acute Endometritis section, or acute endometritis. In accordance with modern classification conditionally distinguish endometritis:

1. Specific. The trigger mechanism for the development of inflammation is, in fact, any microorganisms that are present in the vagina, except for bifidobacteria and lactobacilli, that is, the same ones that can cause acute endometritis. However, the most common are ureaplasma and genital herpes virus (about 80%), cytomegalovirus, chlamydia, mycoplasma, gardnerella and microbial associations.
2. Nonspecific, in which no specific infectious pathogens are detected in endometrial cells. In these cases, predisposing factors are predominantly long-term use of intrauterine contraceptives, untreated long-term bacterial vaginosis, HIV infection, and radiotherapy in oncological diseases of the pelvic organs.

Clinical manifestations

The disease is characterized by non-specific clinical manifestations, a long course, a small number of symptoms and their lack of expression or no symptoms at all (in 35-40%), the presence of erased forms. The clinical course is a reflection of the depth of functional and structural changes in the endometrial tissue. Main clinical symptoms:

1. Profuse bleeding during menstruation and increase in their duration.
2. Scanty discharge of blood during menstruation, the volume of which does not even reach physiological (50 ml).
3. Bloody, serous or seropurulent leucorrhoea or bleeding between periods.
4. Violation of the cycle of menstruation.
5. Periodic, less often persistent, unexpressed pulling pains in the lower abdomen and dyspareunia.
6. Infertility, recurrent miscarriage (miscarriages) and unsuccessful attempts at IVF or embryo transfer.

Diagnostic methods

Diagnosis of chronic endometritis is based on the analysis of the following data:

• anamnesis (history) of the disease;
• symptoms, if any;
• microscopic examination of smears from the vagina, cervical and urethra;
• culture results for microflora, polymerase chain reaction(PCR) of the contents of the vagina, the uterine cavity and secretions from the cervix.
• transvaginal ultrasound of the small pelvis with dopplerography at 5-7 and 22-25 days after the onset of menstruation.
• hysteroscopy and endometrial biopsy in the first half of the menstrual cycle (7-11 days).

How to treat endometritis of the uterus in a chronic course

Mainly used by practitioners step-by-step scheme treatment of chronic endometritis. Its principle is:

1. Stage I - elimination (removal) of infectious agents from the endometrium.
2. II - restoration of the level of cells of the immune system.
3. III - restoration of the structure of the endometrium and the expression of its receptors (sensitivity of a specific cellular receptor apparatus to the action of estrogens and progesterone).

Stage I includes combinations of broad-spectrum antibiotics that can easily penetrate into the cell:

• drugs from the group of nitroimidazoles with macrolides latest generation;
• 3rd generation cephalosporins with macrolides;
• macrolides with protected penicillins, for example, "Amoxacillin + Clavulonic acid";
• nitroimidazoles with fluoroquinolones.

One of these combinations is used from the 1st day of menstruation for 5-10 days. At the same time, antifungal drugs are prescribed - Levorin, Fluconazole, Ketoconazole, etc.

In the presence of anaerobic pathogens in the culture of smears, Metronidazole is added - an average of 10 days. Combined infection is an indication for use vaginal suppositories and others with combined antimicrobial agents (Polygynax) or antiseptics (Hexicon).

If a viral-type infection is detected after antibiotic therapy, a course of treatment with antiviral and immunomodulatory drugs is carried out.

Stage II consists in the use of hepatoprotective, metabolic (vitamins, antioxidants, macro- and microelements), enzyme, immunomodulatory (bioflavonides) and microcirculation-improving agents.

At stage III, the maximum importance is given to physiotherapeutic methods. For this purpose, laser therapy is used, including intravenous blood irradiation. laser beams(ILBI), plasmapheresis, mud therapy, magnetotherapy, iontophoresis with copper and zinc ions. In addition, stimulation of receptor expression is carried out through courses of cyclic hormone therapy with progesterone (Dufaston) and estrogens, as well as phytoecdysteroids.

There is controversy among researchers regarding the need for antibiotics and antibacterial agents. Some of them believe that in the absence of obvious inflammatory processes, antibiotics have no effect and can lead to dysbacteriosis. However, most clinicians are of the opinion that endometritis therapy cannot be sufficiently effective if the microbial factor is underestimated and without the use of antibiotics.

Differences between endometritis and endometriosis

Endometriosis is a benign proliferation of tissues that, in their morphological characteristics and functional properties, are similar to the endometrium. These tissues include not only the upper layer of the latter, but even glandular cells and a connective tissue supporting structure (stroma). However, they are only similar to healthy endometrial tissue.

Molecular defects and genetic changes in endometrioid cells provide them with the ability to grow into neighboring tissues and metastasize with blood and lymph to more distant organs, where they grow and destroy healthy tissue.

Endometrial foci can be localized on the uterine appendages and in the space behind it (Douglas space), on the septum between the rectum and vagina, on the peritoneum, on the surface of the walls of the intestine and bladder, in skin scars left after laparoscopy. Foci of endometriosis are found even, which happens much less frequently, in the vagina and bladder, in the brain and spinal cord, in the lungs.

This disease is a long and progressive process that occurs with exacerbations. It can contribute inflammatory processes but is not their cause. Endometriosis is similar in its properties to malignant tumors, has nothing to do with inflammatory and immune processes in endometritis and is completely different from them in the clinical course and the results of laboratory diagnostic studies.