Chlamydial Infections of the Female Genital Tract
Contents of this Page
- Transmission and Early Symptoms
- Cervical Changes
- Microscopic Changes in the Cervix
- Changes in the Endometrium
- Ovarian Involvement
- Treatment of Chlamydia Infection
- Reproductive Issues
Chlamydia trachomatis invades the body through mucosal surfaces. Infections of the mucous membranes of the eyes with Chlamydia trachomatis were the most common cause of tropical blindness (trachoma) prior to the antibiotic era. During the latter part of the twentieth century, research conclusively documented an association between Chlamydia trachomatis and a host of genital tract infections, both in males and in females, and their role in causing infertility. Recently Chlamydia infections have been implicated in many other diseases which were previously believed to have genetic or environmental causes.
Transmission and Early Symptoms
Human transmission of Chlamydia trachomatis occurs through genital, nasal or rectal mucosa. Infection with Chlamydia trachomatis is completely asymptomatic in about 60% of cases where the female genital tract is colonized. Mild symptoms, often ignored, could present in the form of increased vaginal secretion, a cloudy yellowish or greenish discharge, and diminished cervical mucus during ovulation. The 40% who are symptomatic would complain of local irritation, from mild discomfort to disabling painful intercourse commonly associated with cystitis and other symptoms related to urination. All too often this stage of the infection is attributed to yeast and managed accordingly. If the discharge shows greenish discoloration with numerous bacteria and cocci present under microscopic examination, women seen in office GYN practices would receive Clindamycin vaginal cream (recommended for bacterial vaginosis) or Flagyl (metronidazol) if Trichomonas infection is suspected. Fortunately both of these antibiotics have a wide spectrum against Chlamydia trachomatis. Therefore in many cases despite inaccurate diagnosis the prescribed therapy often alleviates the symptoms. In our experience Chlamydia cervicitis is often accompanied by the overgrowth of aerobic and anaerobic bacteria. By infecting monocytes and polymorphonuclear leukocytes the invasion of Chlamydia reduces local resistance and allows other bacteria to colonize the upper vagina and cervical canal (bacterial vaginosis)
The visual appearance of a chronically inflamed cervix secondary to Chlamydia trachomatis infection will show ectropion (a protrusion of the inflamed cervical mucosa around the cervical opening) with a minimal to significant quantity of clear to cloudy cervical mucous. Figure 1 shows the colposcopic appearance of a nulliparous (never pregnant) cervix with moderate ectropion Infection of the cervical canal is suspected if and when the patient reports a diminished and altered cervical secretion during ovulation.
Microscopic Changes in the Cervix
Microscopically the sticky and cloudy mucous reveals numerous white blood cells and lymphocytes, Figure 2 a (Low and high power). Not uncommonly, sloughed off islands of endocervical lining cells are seen in the mucous, Figure 2 b. The sub mucosa of the endocervix shows diffuse polymorphonuclear leucocytic infiltration, Figure 3. In deeper layers of the cervix, the infection stimulates young fibroblasts in whorl like formations, Figure 4 a, constricting cervical glands with extensive hyalinization, Figure 4 b. The oldest lesions will show calcium deposits, Figure 4c. As constriction of the outflow ducts from the cervical glands progress, complete obstruction will lead to the formation of Nabothian cysts, Figures 5a and b. Figure 6 a. is a sonography picture of a longitudinal section of the cervix showing bead like scarring with calcium deposits. The lighter gray color is due to scar tissue formation and reduced blood flow to these areas. Calcium deposits cause the brilliant white specks. Figure 6 b. shows a cross section of the cervix with focal scarring.
Changes in the Endometrium
Except for severe infections, monthly shedding of the endometrium prevents the progression of the local infection to scarring and calcium deposits in endometrial biopsies. Most specimens however are still obvious for inflammatory cell infiltration. Figure 7. In severe endometrial infection with Chlamydia scarring can completely obliterate the endometrial cavity. Figure 7a.
Chronic severe Chlamydia infection. Endometrial cavity obliterated with scar tissue.
Clinically, the patient would report diminished menstrual flow and brownish discoloration at the beginning of the flow. The tail end of the period is again described as brownish staining. The explanation for this phenomenon is the different intensity of the infection in different parts of the uterine lining. The flow starts with staining from the lesser-involved areas that mature first, then the bulk of the lining will shed where the inflammation is about the same in all areas. The most involved areas will mature last and will make up for the tail end of the flow with a few days of brownish staining. Additional clinical symptoms include diminished menstrual cramps, due to diminished prostaglandin secretion within infected endometrium, lack of a triple layer in the sonogram picture of a luteal phase endometrium, Figure 8 and delayed development of the lining, a condition referred to as luteal phase defect. If a series of D&Cs are performed to remove remnants of miscarriages from an infected uterine cavity, the menstrual flow may completely stop due to adhesions that develop between the anterior and posterior walls of the uterus.
Irregularities in ovulation, development of PMS, decreasing sex drive and gradual elevation of day three FSH level will signal ovarian involvement.
Treatment of Chlamydia Infection
Treatment should start by removing the endocervical and endometrial scarred and damaged epithelium. The histological examination will show acutely or chronically infected tissues. A florescence micrograph of tissues stained with anti-Chlamydia trachomatis fluorescein labeled antibodies show reticulate bodies within epithelial cells and elementary bodies outside the epithelial cells. See Figure 8. An antibiotic regimen should include both intravenously administered antibiotics and uterine washes. Following this initial therapy, long term oral regimens are prescribed using combination antibiotics.
Special considerations are necessary for the management of pregnancies. Due to the immune suppressed state of pregnancy, intracellular resting forms (or spore forms) of Chlamydia trachomatis can proliferate and complicate pregnancy. Post conception antibiotic therapy and intermittent antibiotic therapy throughout the course of pregnancy constitute an integral part of the management.
Microscopic Pictures Documenting Female Chlamydial Infection
Figure1. Photomicrograph showing acute cervicitis with ectopic endocervix (ectropion) found in a patient with history of chronic bacterial vaginosis and positive finding for Chlamydia trachomatis. The squamo-columnar junction is visible and the reddish discoloration over the exocervix is caused by local inflammation. Colposcopy image magnified x1.5
Figure 2 a. Polymorpho-nuclear leukocytes crowd the cervical mucous with occasional lymphocytes also present. Numerous bacterial forms also present
Figure 4 a. Whorl like proliferation of young fibroblasts is obvious in the stroma. H and E X400.
Figure 4 b. The hyalinized stroma occludes glandular structures. Older fibroblast proliferation next to glandular structures shows partial hyalinization (white arrow).
Figure 4 c. The oldest lesions show cellular elements displaced by collagen (red arrow). The central areas show calcification (white arrow). H and E, X400.
Figure 5a. Fibrous tissues forming around outflow ducts of cervical glands create gradual occlusion, the first step in the formation of Nabothian cysts.
Figure 5b. Early stage of duct occlusion shows marked glandular dilatation, a precursor for Nabothian Cysts. H and E X400.
Figure 6 a. Sonography picture of longitudinal section of the cervix showing beads like scarring with calcium deposits. The lighter gray color is due to scar tissue formation and reduced blood flow to these areas. Calcium deposits cause the brilliant white specs.
Figure 6 b. Cross section of the cervix with focal scarring.
Figure 7 shows endometrial specimen from day 17 of the cycle. Sub mucosal polymorphonuclear leukocytes and stromal lymphocytes are in excess.
Figure 8 Ultrasound photomicrograph of day 17 endometrium that shows haphazard development of endometrium without triple layer present
Figure 8. Oil immersion micrography of reticulate bodies within epithelial cells from curettage X1000. The slides are counter stained with hematoxiline for cell structure identification