Autoimmune Oophoritis – Causes, Symptoms, Treatment

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Autoimmune oophoritis is an uncommon, non-neoplastic, autoimmune inflammation of ovaries, a chronic process in which the affected organ is destroyed by massive cellular infiltration of foamy histiocytes admixed with multinucleated giant cells, plasma cells, fibroblasts, neutrophils, and foci of necrosis resulting in their destruction, atrophy, and fibrosis with a loss of fertility and ovary hormonal production. These changes stop the ovaries from working normally.

The most commonly affected organs are the kidney and gallbladder, followed by the anorectal area, bone, stomach, and testis (). If the inflammation occurs in the female genital tract, it more commonly affects the endometrium but the vagina, cervix, fallopian tube, and ovary can also be affected. The ovarian involvement is rare and is characterized by a massive infiltration of the tissues by lipid-laden histiocytes admixed with lymphocytes, plasma cells, and polymorphonuclear leukocytes ().

Autoimmune oophoritis is one of a larger group of autoimmune endocrinopathies in which immunological self-tolerance to hormone-producing organs fails. Currently, the histopathological analysis of the ovary is the only way to definitively diagnose autoimmune oophoritis, although due to the general inaccessibility of the ovaries, this is often not attainable., Instead, the majority of women with POI are diagnosed based on the presence of antibodies reactive against ovarian tissue. Further, autoimmune POI is almost always associated with autoimmunity against other organs, in particular, autoimmune Addison’s disease and the presence of serum autoantibodies targeting the adrenal gland., Thus, the incidence of autoimmune POI that is associated with these autoantibodies is approximate 4%.

What are the symptoms?

In some cases, this condition doesn’t cause any symptoms. It may not be diagnosed until a sudden bout of severe pelvic pain prompts you to seek medical attention.

Other times, symptoms may be mild and hard to recognize as anything out of the ordinary. Douching can also mask early symptoms, delaying diagnosis.

See your doctor if you’re experiencing any of the following:

  • pain in the lower abdomen and pelvis
  • menstrual bleeding that’s heavier than usual
  • bleeding between menstrual cycles
  • pain or bleeding during intercourse
  • heavy vaginal discharge, which may have a foul odor
  • burning sensations or pain during urination
  • difficulty urinating

These symptoms may come on gradually or all at once. They can also increase in severity over time. These symptoms can also be caused by other conditions.

As time wears on without a diagnosis, this condition can cause:

  • fever
  • chills
  • vomiting

Oophoritis is usually the result of sexually transmitted infections (STIs) like chlamydia and gonorrhea. You can reduce your risk by practicing safe sex with all partners.

Bacteria can also get into the reproductive tract through your cervix. This can happen:

  • if an intrauterine device (IUD) is inserted incorrectly
  • during an abortion
  • after a miscarriage
  • during childbirth

It isn’t clear what causes autoimmune oophoritis. In rare cases, this form can result in primary ovarian insufficiency (POI).

History

  • Abdominal pain
  • Pelvic pain
  • Vaginal discharge
  • Dyspareunia
  • Fever
  • Chills
  • Nausea/vomiting

Physical

  • Temperature greater than 38C
  • Abdominal tenderness in lower quadrants
  • Rebound tenderness (possible) on pelvic exam
  • Mucopurulent discharge
  • Cervical motion tenderness
  • Adnexal tenderness
  • Adnexal mass (if TOA present)
  • Unprotected sexual intercourse
  • Multiple sexual partners
  • High-risk sexual behavior
  • Immunosuppression
  • Recent instrumentation of genital tract (endometrial biopsy, intrauterine device [IUD] placement)
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How is it diagnosed?

After reviewing your symptoms and medical history, your doctor will perform a physical exam. They’ll also run tests to determine if there’s an underlying infection or if there are any abnormalities near your ovaries and fallopian tubes.

Lab Studies:

  • CBC – Elevation of the white blood cell count (WBC) to more than 10 K is a nonspecific indicator of infection. Early in the onset, however, the WBC may be normal.
  • Urinalysis – To rule out cystitis
  • Urine pregnancy test – To rule out ectopic pregnancy
  • Wet prep of cervical discharge – Shows numerous WBCs and bacteria
  • Cervical cultures for gonococcus (GC) and Chlamydia – To rule out or diagnose and treat infection with these organisms (immediate results will not be available).

Imaging Studies

  • Pelvic ultrasound may be needed if the physical exam does not allow for thorough palpation of the adnexa. This occurs commonly because patients guard due to the pain they experience. An ultrasound examination will rule out the presence of a TOA. However, if a TOA is not present the ultrasound will probably not be helpful.

Other Tests:

  • Diagnostic laparoscopy is the definitive test, usually reserved when the diagnosis is unclear.
  • Perform serologies for hepatitis B virus, hepatitis C virus, syphilis, and HIV, since these can be found in patients engaging in high-risk sexual behaviors.

Histologic Findings 

For cases evaluated by surgery, an abscess involving the fallopian tubes and ovaries may be seen.

These tests include:

  • Blood and urine tests. These tests are used to determine your white blood cell count, as well as look for markers of inflammation. They also help your doctor rule out other diagnoses, such as cystitis.
  • Pelvic exam. This allows your doctor to look for PID symptoms.
  • Pelvic ultrasound. This imaging test is used to view your internal organs. Your doctor may perform both a transabdominal and a transvaginal ultrasound to get as much information as possible about your pelvic region. They’ll also assess the size of your ovaries and check for cysts or abscesses.
  • Laparoscopy. If your doctor suspects salpingo-oophoritis, they’ll use this surgical test to view your fallopian tubes. To do this, they’ll insert a slender, lighted telescope through an incision in the lower abdomen. This will allow them to view your pelvic organs and remove any blockages.

Treatment of

The underlying cause will determine your treatment options. For example, if you have an active STI, your doctor will prescribe antibiotics. Abscesses may also be treated with antibiotics.

In some cases, surgery may be needed to drain infected abscesses. Surgery may also be used to remove blockages or pelvic adhesions.

Women who have autoimmune oophoritis may benefit from hormone replacement therapy. They may also need specific treatments for their underlying condition.

If you’re experiencing pain, talk to your doctor about your options for relief. For some women, over-the-counter pain relievers and applied heat are enough to reduce symptoms. Others may benefit from stronger pain medications.

Complications

If left untreated, this condition can cause extensive damage to the ovaries and fallopian tubes. Fallopian tube damage can increase your chance of having an ectopic pregnancy.

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Sometimes, fallopian damage can result in infection. If the infection is left untreated, and an abscess bursts, it can lead to sepsis. Sepsis can be life-threatening.

Pregnancy and fertility

If treated early, infectious oophoritis can be treated before it has an effect on your fertility. If treatment is delayed, your fertility may be compromised by scar tissue and blockages. These can sometimes be removed surgically, allowing you to conceive.

If your doctor is unable to remove these obstructions, they may recommend in vitro fertilization (IVF). IVF bypasses the fallopian tubes, increasing your chances of conception. If both ovaries are damaged, working with an egg donor may provide a way for you to become pregnant.

There isn’t a cure for autoimmune oophoritis or its complication, POI. This is a challenging diagnosis, and it can have a negative impact on your fertility. Talk to your doctor about your ability to conceive. They can walk you through your options and advise you on your next steps.

Drug Category: Antibiotic— Antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Drug Name Ceftriaxone (Rocephin) — Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins. Considered first-line treatment (in conjunction with doxycycline) for outpatient management of PID.
Adult Dose 250 mg IM once
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Pregnancy B – Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in renal impairment; caution in breast-feeding women and allergy to penicillin
Drug Name Doxycycline (Vibramycin) — Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Used in conjunction with ceftriaxone or cefoxitin for outpatient treatment of PID.
Adult Dose 100 mg PO bid for 14 d
Pediatric Dose <8 years: Not recommended
>8 years: Not established
Contraindications Documented hypersensitivity, severe hepatic dysfunction
Interactions Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy D – Unsafe in pregnancy
Precautions Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 years) can cause permanent discoloration of teeth; Fanconi-like syndrome may occur with outdated tetracyclines
Drug Name Cefoxitin (Mefoxin) — Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin. For inpatient treatment of PID, cefoxitin and doxycycline in conjunction are considered first-line therapy.
Adult Dose 2 g IV q6h until clinical improvement for 48-72 h
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Pregnancy B – Usually safe but benefits must outweigh the risks.
Precautions Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis
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Drug Name Gentamicin (Garamycin) — Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Gentamicin and clindamycin are second-line agents for inpatient treatment of oophoritis.
Adult Dose 2mg/kg loading dose IV, then 1.5 mg/kg IV q8h; continue until clinical improvement for 48-72 h
Pediatric Dose Not established
Contraindications Documented hypersensitivity, non䤥ialysis-dependent renal insufficiency
Interactions Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Pregnancy C – Safety for use during pregnancy has not been established.
Precautions Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Drug Name Clindamycin (Cleocin) — Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. Used in conjunction with gentamicin as second-line treatment for oophoritis.
Adult Dose 900 mg IV q8h; continue until clinical improvement for 48-72 hrs
Pediatric Dose Not established
Contraindications Documented hypersensitivity, regional enteritis, ulcerative colitis, hepatic impairment, or antibiotic-associated colitis
Interactions Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay the absorption of clindamycin
Pregnancy B – Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Drug Name Ampicillin (Marcellin, Omnipen) — Used in conjunction with gentamicin and clindamycin for added enterococcus coverage. Usually added if gentamicin and clindamycin do not yield the desired clinical result.
Adult Dose 2 g IV q6h
Pediatric Dose None reported
Contraindications Documented hypersensitivity
Interactions Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Pregnancy B – Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in renal failure; evaluate rash and differentiate from a

hypersensitivity reaction

 

 

References

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