Physical examination in a simple case of chronic endometritis shows a somewhat enlarged uterus, more globular in shape than normal. The fundus uteri is tender on pressure between the vaginal finger and the abdominal hand. The external os is usually patulous.
Examination with the speculum shows the discharge escaping from the external os. If there is also present cervical endometritis, the discharge presents the characteristics of both cervical and corporeal mucus. It is thick and tenacious, puriform, and often streaked with blood. After the cervical canal has been wiped out the characteristic corporeal discharge may appear unmixed with cervical mucus. This discharge is thin, purulent, and may be streaked with blood, or it may be brownish in color from mixture with altered blood.
If the uterus is examined with the uterine sound, it will be found that the internal os is patulous; the fundus is decidedly tender upon gentle pressure with the sound, and even the gentlest use of the sound may be followed by bleeding.
The patulous condition of the cervical canal and the internal os is a constant characteristic of all kinds of gross disease in the cavity of the uterus. The external os is usually patulous when the cervical mucous membrane is diseased. The external os, the cervical canal, and the internal os are open when the corporeal endometrium is diseased.
The only certain method of making the diagnosis is by the use of the sharp uterine curette, and this instrument should always be employed whenever there is even the slightest suspicion of the possibility of malignant disease of the endometrium. The cervical canal is usually sufficiently open to permit the use of the curette without dilatation and without an anesthetic. Three or four strips of the endometrium should be removed from different parts of the uterine cavity, and should be submitted to microscopic examination. It is always safest to perform curetting for diagnosis at the house of the patient, and to keep her in bed for two or three days after the operation. Strict antisepsis should be observed.
The causes of chronic corporeal endometritis are various. Almost any disease of the body of the uterus or of the cervix may eventually result in this condition; therefore the different causes of chronic endometritis will be better appreciated after a discussion of diseases of the uterus. Laceration of the cervix, subinvolution, flexions and versions, fibroid tumors, etc., all produce, in time, some form of chronic endometritis.
Primary chronic endometritis may result as a later stage of the acute disease, or it may exist from the beginning in the chronic form. This is especially true of endometritis caused by gonorrhea. Here the invasion of the disease is slow and insidious, and in the majority of cases is preceded by no determinable acute stage.
Sometimes endometritis appears in old women. Bleeding from the uterus, purulent discharge, and pain may be present. The condition is due to the atrophic changes of senility occurring in the endometrium—changes that resemble those that take place in the mucous membrane of the vagina and the external genitals. Though such symptoms may be indicative merely of a benign condition, yet, as they are also characteristic of the early stages of malignant disease, they demand immediate thorough examination and careful watching.
Treatment.—As chronic endometritis is usually secondary to some disease of the cervix or body of the uterus, the treatment should be directed toward the cure of this primary condition.
The operation of trachelorrhaphy will cure the subinvolution of the uterus and the resulting endometritis. Forcible dilatation of the cervix, in the case of an old anteflexion, will relieve the inflammation of the endometrium. Correction of a retroversion will likewise relieve the resulting endometritis. Therefore, though in every case the cure may be hastened by treatment applied directly to the endometrium, yet causative or complicating conditions must always also be treated if we wish the cure to be lasting.