**4. Hysteroscopic diagnosis**

A hysteroscopy, performed in the proliferative phase of the menstrual cycle, allows to identify the signs of endometrial inflammation.

Under examination with CO2, chronic endometritis typically presents with endometrial areas, which are bright red with white central dots, focally or diffusely distributed over the endo‐ metrial surface, assuming an appearance considered to resemble a 'strawberry' pattern, similar to the colposcopic pattern 'punctated with white spots'.

Other findings may be conspicuous due to the presence of friable, white patches that bleed easily on contact. These features are, however, very unspecific, as they may also be related to lesions of the vascular bed in reaction to the intracavitary CO2 distension medium, or emerging due to immunological disorders, or hypertension, and they may yet be so mild as to evade diagnosis.

Uterine distension with saline has, among other advantages, that of causing no adverse side effects on endometrial microcirculation, thus facilitating the diagnosis of chronic endometri‐ tis [25].

**•** *Leucorrhea and urinary symptoms*: occasionally, there is a malodorous, purulent vaginal discharge, with increased urinary frequency and/or symptoms similar to those of cystitis,

Tubercular endometritis merits special mention; this type of chronic endometrial inflammation virtually always occurs secondary to respiratory or abdominal localization, with a clear predilection for adnexal localization. It is generally limited to young women of childbearing

The symptomatology varies from overt forms, in which the inflammatory process has affected the appendages, to completely latent forms. In the presence of tubercular endometritis, changes in menstrual flow may occur, ranging from polymenorrhea to amenorrhea, accom‐

The diagnosis of chronic endometritis by means of two-dimensional transvaginal sonography (TVS) is difficult due to the absence of pathognomonic signs associated with the condition [12].

**•** increase in endometrial thickness, asynchronous with the phase of the menstrual cycle.

A hysteroscopy, performed in the proliferative phase of the menstrual cycle, allows to identify

Under examination with CO2, chronic endometritis typically presents with endometrial areas, which are bright red with white central dots, focally or diffusely distributed over the endo‐ metrial surface, assuming an appearance considered to resemble a 'strawberry' pattern, similar

Other findings may be conspicuous due to the presence of friable, white patches that bleed easily on contact. These features are, however, very unspecific, as they may also be related to lesions of the vascular bed in reaction to the intracavitary CO2 distension medium, or emerging due to immunological disorders, or hypertension, and they may yet be so mild as to evade

**•** *Fever*: Elevated in the acute phase; in some cases, a mild fever in the chronic form.

along with concomitant bladder irritation.

panied by an almost universal history of sterility/infertility.

age, being rare in the menopause.

38 Genital Infections and Infertility

**3. Prehysteroscopic diagnosis**

Indirect sonography signs are as follows:

**•** endometrium with hyperechogenic spots;

**•** hematometra;

diagnosis.

**•** intracavitary synechiae;

**4. Hysteroscopic diagnosis**

the signs of endometrial inflammation.

to the colposcopic pattern 'punctated with white spots'.

The criteria proposed by Cicinelli et al. [26] to establish a hysteroscopic diagnosis of chronic endometritis are as follows (Figures 1–3):


**Figure 1.** Hysteroscopic view of chronic endometritis in a 30-year-old infertile woman. Saline used as distension medi‐ um does not affect endometrial microcirculation, making it easier to identify the characteristic signs of chronic endo‐ metritis. Note the micropolyps, which appear as small pedunculated, vascularized protrusions (<1 mm) on the uterine mucosa (A). The close-up view clearly shows a marked accentuation of the vascular network at the level of the uterine fundus (B). To right, an overt stromal edema is evident (C), though the examination was carried out in the early prolif‐ erative phase.

**Figure 2.** Hysteroscopic view of chronic endometritis in a 34-year-old woman with a positive anamnesis of three early spontaneous abortions (A–C). The stromal edema is clearly evident on the posterior wall (A) and micropolyps are de‐ tected on any of the uterine walls (A–C).

A study led by Cicinelli in 2005 [26] showed that the absence of stromal edema and hyperemia —detected at hysteroscopy—has a high negative predictive value (98.8%), i.e., the absence of

**Figure 3.** Detail of micropolyps under hysteroscopic examination using a liquid distension medium: the micropolyps, which appear with a varied morphology, are scattered over the uterine wall and may often be encountered with pol‐ yps (A) and/or pseudopolyps.

these findings allows the hysteroscopist to rule out, with reasonable certainty, the presence of endometrial inflammation.

Conversely, if micropolyps are found, which is almost always associated with hyperemia or stromal edema, this should be interpreted a reliable sign of inflammation, as corroborated by the high positive predictive value attributed to this finding (98.4%).

The presence of focal hyperemia with isolated micropolyps is associated, histologically, with a mild type of endometrial inflammation; conversely, the findings of generalized hyperemia, diffused micropolyps, or a thickened endometrium with polypoid diffusion are all associated with moderate-to-severe endometrial inflammation [27, 28].

In summary, the presence of hyperemia, edema, and stromal micropolyps has a demonstrated diagnostic accuracy of 93.4%.

The potential development of endometritis, if left untreated, leads to the formation of intrau‐ terine synechiae.

Regarding tuberculous endometritis, certain hysteroscopic signs suggestive of disease have been described, such as the presence of a thin, uneven, and pale endometrium with irregular whitish spots scattered over the uterine walls [29].

It is not uncommon to observe intrauterine adhesions, while a much rarer finding is the presence of classic tubercles in the endometrial mucosa. Differential diagnosis should be established against the presence of granulomatous endometritis (sarcoidosis) and that of the fungal form [30]. Even CMV-related endometritis can manifest itself in the granulomatous form.

Finally, there is a rare form of endometritis that may mimic, at macroscopic level, an endo‐ metrial carcinoma [31]. This is xanthogranulomatous endometritis, whose etiology is still under debate, and which occurs predominantly in elderly women with cervical stenosis and pyometra. Histologically, it is characterized by xanthogranuloma, consisting of lipid-rich histiocytes, giant cells, lymphocytes, neutrophils, and plasma cells.
