Veterinary Quarterly

ISSN: 0165-2176 (Print) 1875-5941 (Online) Journal homepage: https://www.tandfonline.com/loi/tveq20

Cystic endometrial hyperplasia‐pyometra complex

in cats. A review

C.F. Agudelo

To cite this article: C.F. Agudelo (2005) Cystic endometrial hyperplasia‐pyometra complex in cats.
A review, Veterinary Quarterly, 27:4, 173-182, DOI: 10.1080/01652176.2002.9695198

To link to this article: https://doi.org/10.1080/01652176.2002.9695198

Copyright Taylor and Francis Group, LLC

Published online: 18 Nov 2011.

Submit your article to this journal

Article views: 3717

View related articles

Citing articles: 24 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=tveq20
 173

Veterinary Quarterly 2005; 27(4): 173-182

Cystic endometrial hyperplasia-pyometra complex in cats.

A review
C.F. Agudelo*

Department of Internal Medicine, Clinic of Dog and Cat Diseases, Faculty of

Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno,
Czech Republic

TABLE OF CONTENTS

Summary and keywords 174

Short description 174

Etiopathogenesis and epidemiology 174

Clinical signs 176

Diagnosis 177

Treatment 178
Ovariohysterectomy 179
Medical treatment 179

Conclusions 181

References 181

*Address: Clinic of Dog and Cat Diseases, Faculty of Veterinary Medicine,

University of Veterinary and Pharmaceutical Sciences,
Palackého 1/3, Brno, Czech Republic
E-mail: cagudelo@vftc.cz
 174

Cystic endometrial hyperplasia-pyometra complex in cats.

A review
C.F. Agudelo

SUMMARY
Presentation of complex cystic endometrial hyperplasia-pyometra is not very common in cats. As in
bitches, hormonal influences result in environmental and histological changes in the uterus leading to
predisposition to bacterial growth. Its influence on the organism provokes certain clinical signs.
Diagnosis and treatment must be fast and aggressive. Depending on the clinical status and queen
purpose, it can be both surgical or medical. Both of them offer a high rate of success if the detailed
protocols are followed.

Keywords: Cat diseases; CEH; Corpora lutea; Cystic endometrial hyperplasia-pyometra complex; Endome-
tritis; Ovariohysterectomy; Progestagens; Prostaglandins; Pyometra; Queen; Uterine diseases.

Short description follicular cycles (9). Estrous returns whithin 14-19

Cystic endometrial hyperplasia-pyometra is a
disease, which is mainly characterized by
progesterone-induced hyperplasia of the endometri-
urn with cystic dilatation of the endometrial glands
and inflammation of the uterus with purulent con-
tent in the uterine lumen leading to several clinical
signs (2,5,20,33, 34).
Etiopathogenesis and epidemiology
It is important to realize that the queen is a species
with induced ovulation, which requires coitus or
mechanical stimulus of the cervix or the vagina to
liberate luteinizing hormone (LH) and subsequent
ovulation (11,12,17,18,19,40). Coitus as an
external trigger stimulates the release of
gonadotropin releasing hormone (GnRH) from the
hypothalamus. GnRH stimulates release of LH
from the anterior hypophyseal gland in the
subsequent minutes with a peak 4 hours. later.
Ovulation occurs 30 to 50 hours after coitus
(17,29). It has been observed that the increase of
the number of copulations accounts for higher
magnitude and longer duration of liberation of LH
with higher ovulation probability when compared
with one mating only (14,15,19,28,31). Corpora
lutea start to produce progesterone 24-48 hours
after ovulation (17). When this happens, this phase
corresponds to the pregnancy or pseudopregnancy
(when the queen is not pregnant). This phase
comes to an end after 40-50 days (9,10,14,17).
The whole period of progesterone influence over
uterus is shorter when compared to the bitch (over
60 days) (10,40). Queens are not affected by
progesterone influence between non-ovulatory
days after a non-ovulatory cycle (17).
The hormone progesterone causes, a)hyperplasia of
the endometrium, especially of the superficial
epithelium and the endometrial glands (17),
b)
closure of the uterine cervix(27), °increase of the
secretory activity of the endometrial glands (2,10,
20,27,33,34,37,40), and °decrease of myometrial
contractibility, although it can be hyperplastic
(17). Intrauterine leukocytary response suppression
to foreign stimulus has been reported (5,40). The
first phase of the illness is the proliferation and
cystic dilation of the glandular endometrium with
fluid accumulation in the uterine lumen. The
ocurrence of this phase is influenced by age and
hormonal stimuli, and is denominated cystic
endometrial hyperplasia (CEH) (17,20,22,27).
Changes in the uterine microenvironment and
decreased contractibility would favor ascendant
bacterial infection (2). During pseudopregnancy,
the changes induced by the progesterone on the
glandular epithelium begin to disappear after 4
weeks, while during pregnancy endometrial
morphology and synthetic activity continues
simultaneously with the pregnancy (12).
However, these findings are not consistent; recent
information shows that queens can have spontane
ous ovulation after a non fertile breeding (16,17,
18,19,40) or after pharmacological treatments (4,
12,27,39). It has been observed that some queens
were in luteal phase, though they were separated
from males and have not received any therapy.
This suggests that the luteal phase can be induced
by diverse factors (2,14,16,29) (visual, tactile, etc.
[33,17]).
 175

It has been noticed that progesterone is not the
only hormonal factor involved in the process.
Some queens have been diagnosed with pyometra
in follicular phase of the ovarian cycle (36,40).
This can be due to the non-gestate uterus
diestrus that is flaccid and contains some endome-
trial gland secretions that were developed previ-
ously as a response to the risen estrogen level in
time of the estrous (5,40). Recent information
shows that pyometra is not only influenced by
progesterone but also estrogens (29,40). Estrogens
a)increase progesterone receptors in the endometri-
urn, °dilate uterine cervix, allowing bacterial
ascent that is part of the normal vaginal flora and
c)can influence endometrial changes. These endo-
metrial changes are influenced by chronic estroge-
nic stimulation from recurrent estrous cycles,
which do not end in pregnancy (5,17,20). This all
explains why cystic endometrial hyperplasia (CEH)
was not experimentally induced with any hormonal
treatment (29).
CEH is a common histological finding in nullipa-
rous queens older than 3 years and in other queens
older than 5 years with no relationship to the
number of parturitions (10,12,29,36), although it
has been mentioned that these proportions are very
similar (8,10). Pyometra has been observed in
queens older than 8 years and in younger queens
after progestagen administration (20,21).
average age of cats with pyometra is 7 years
(2,14). Elderly nulliparous queens would be more
likely to develop the disease due to the endometrial
changes above discussed (13,17,28). Some patients
have experienced estrous 8 weeks prior to diagno-
sis and in many cases it is not known whether
there was mating (2,12,40). There is no correlati-
on between the development of the disease, the
age of the first mating or parturition and number
of litters delivered. On the other hand, correlation
has been observed between pyometra and corpora
lutea presence (2). In about 40-70% of the cases
corpora lutea were present (13).
In most cases of of CEH-pyometra complex
in
bacterial infection originates from the normal
opportunistic flora of the vagina. The abnormal
endometrium can be a predisposing factor to the
bacterial colonization (2,12,21,33,40). Less
frequently bacterial infection is of haematogenous
origin (5). Pyometra can be a type of CEH
associated with predominance of inflammatory
cells inside the uterine lumen and secondary
bacterial infection (12,17). Pyometra and CEH
frequently coexist, although both abnormalities can
represent a single pathological process. A certain
grade of CEH is found in every queen with
pyometra, except for a number of cases of pyome-
tra with closed cervix, because in these cases there
is already endometrial atrophy (12).
Aerobic bacteria are recovered from approximately
80% of the animals (39). Escherichia coli is the
most frequently isolated microorganism from feli-
ne pyometras (5,11,12,14,16,17,18,19,20,33). The
role of bacteria in the pathogenesis of the CEH-
pyometra complex is especially important in the
luteal phase. Isolated bacterial strains from patients
with pyometra can be biochemically simi-lar to
their faecal homologous suggesting faecal contami-
The nation of the genitourinary tract (2). Other agents
like Streptococcus, Staphylococcus, Klebsiella,
Pseudomona, Proteus, Moraxella and Pasteurella
have also been reported (10,12,29,33,34). Myco-
plasma, although it has not been proven in cats
should also be suspected (14,30). Uterine tubercu-
losis and brucellosis acquired from infected bovine
tissues have also been reported in the cat (14).
A CEH classification has been established in cats
according to the clinical, paraclinical and histopa-
thological criteria (7,13,33) (Table 1).

Type of CEH Short description of the characteristics

Type I CEH without inflammatory process, no clinical signs.

Type II CEH with acute endometritis. In most cases presence of corpora lutea. White Blood Count (WBC) increase.
Signs can vary depending on the severity of the endometrial reaction and distention of the uterus, but in
general the cats are ill.
Type III Subacute endometritis with mononuclear infiltration of the endometrium and cystic changes of the endometrial
glands. The clinical signs are more pronounced than in the the preceding types. Important WBC increase.
Type IV Chronic endometritis with endometrial atrophy. The severity of the clinical signs depends among others on the
WBC, the abdominal distention and damage in other abdominal organs.

Table I. CEH classification according to Dow (7).

 176
Use of exogen progesterone in queens with contra-
ceptive purpose can also induce pyometra, especi-
ally in young queens (5,20), even in ovariectomi-
zed queens (14). However, when this application
is controlled, only over long periods CEH effects
and sterility can been seen with consequent deve-
lopment of pyometra (22). Another study demon-
strated that weekly administration of 2 mg chlor-
madinone acetate caused pyometra in two out of
24 treated queens, in connection with mammary
abnormalities (35). Use of exogenous estrogens to
Endometrial hyperplasia index Histopathological features
Grade 0 No hyperplastic changes.
Grade 1 Minimal to mild proliferative and/or cystic changes in glands or surface epithelium without
an increase in overall endometrial height.
Grade 2 Moderate hyperplastic and/or cystic change with an increased endometrial thickness of <2
times normal.
Grade 3 Severe hyperplastic and/or cystic changes with increased endometrial thickness of
normal.
Table 2. Endometrial hyperplasia index according to Munson et al. (22).
This study clearly demonstrated a correlation
between contraception using synthetic progesterone
(megestrol acetate) and the development of
advanced endometrial hyperplasia, which seems to
be irreversible. These results clearly suggest not to
use these kinds of drugs in reproductively and
genetically valuable animals (22).
In recent studies, a functional classification of the
pathologic complex is based on the ovarian phase
(12,17,40). In these studies, queens with
inflammatory uterine disease or infertility with
active corpora lutea showed CEH, myometrial
hyperplasia and increased progesterone . levels
(1,87 ng/ml), while queens with follicular ovaries
did not display these changes and had very low
progesterone levels (0,15 ng/ml) (16). However,
normal ovaries, which are not in luteal phase or
with cystic follicules are found in approximately
15-23% of the queens with pyometra (12).
Endometrial changes induced by progesterone not
necessarily disappear after involution of the
corpora lutea.
Queens with Feline Infectious Virus (FIV)
infection that are or have been pregnant, can
succumb to complicati-ons of reproductive type
(abortion, stillbirth, etc.), in various time after
mating. One study described that 3 out of 13
interrupt gestation can result in pyometra in cats
older than 4 years, because the uterine cervix stays
open longer (20). Doses are reviewed elsewhere in
the literature (22,27,35).
Adenomatous hyperplasia and cystic changes were
combined to determine the overall cumulative
increase in endometrial thickness (endometrial
hyperplasia index) in wild cats. These changes
were presumed to have similar effects on fertility
(5,22). The severity of endometrial hyperplasia
was categorized (Table 2).
<2 times
queens with the above mentioned infection had
:
pyometra (33).
Stump pyometra can be produced similar to that
repor-ted in bitches. This happens because of
administration of progestragens to castrated
queens, which still have uterine remnant (10,14).
Pyometra can also be present in masculine uterus
and hermaphrodites (2,32).
Clinical signs.
Cats with CEH not always show clinical signs, but
it can be associated with implant failure and
subsequent smaller littermates and also infertility
(secondary anestrous) (10,12,28) as well as early
embryonic death (17). In the case of marked CEH,
abdominal distention can be observed because of
fluid accumulation in the uterus (mucometra,
hydrometra) (12,40).
Pyometra and other forms of uterine inflammation
almost always cause clinical signs (12). The most
common clinical finding is vaginal mucopurulent
to hemorrhagic discharge (2,5,8,10,12,15,17,33)
occurring in about 75% of the cases (20).
However, this symptom can also be absent due to
careful cleaning habits of the queens (21,34,40) or
in cases of a closed-cervix pyometra (5). Uterus
can be palpated as a big sized mass and there can
or cannot be abdominal distention (8,12,15,20). In

closed-cervix pyometra the latter is common (10,
21). This finding is more evident in queens than in
bitches (34). In those cases, patients are more
prone to endotoxemia and uterine rupture with
concurrent peritonitis (2,5,17,20). This is the
reason for the need of being careful when carrying
out abdominal palpation to avoid iatrogenic rupture
(29). Non-specific clinical signs such as anorexia,
vomiting, lethargy, loss of weight and unkempt
appearance can also be observed (2,10,12,14,15,
29).
Polyuria and polydypsia do not occur as often as
in dogs. They were reported only in 9% of the
cases (2,12). As reported in dogs, E.
endotoxins interfere with Na+ and Cl absortion in
the loop of Hen le, thereby reducing medullary
hypertonicity and resulting in impaired water
absorption. Additionally E. coli endotoxins block
receptors for antidiuretic hormone on the
collecting ducts, leading to obligatory polyuria
with compensatory polydypsia (21).
In almost one third of the cases severe dehydration
is identifiable at the moment of the clinical
examination, partly due to the advanced stage of
the disease (2,33). Similarly as reported in dogs,
20-25% of the cases show fever (12,20). In cases
with shock signs (tachycardia, tachypnea and poor
peripheral perfusion) hypothermia can be found
(25).
Stump pyometra must be suspected in a castrated
queen with purulent or hemorrhagic vulvar
secretion, being more complicated in cases with
closed-cervix pyometra (9,14).
The most important differential diagnosis for these
historical and physical findings is pregnancy with
concurrent disease (2,12,20), diseases that produce
vaginal discharge such as urinary, uterine and
vaginal diseases (25), diseases that cause increase
of the uterine content (mucometra, hydrometra,
haemometra) and diseases with concurrent abdomi-
nal distention (ascites, obesity, abdominal masses,
congenital disorders, peritonitis) (24,33,35).
Diagnosis
The diagnosis is based on the history, the estrous
cycle status and the clinical signs (estrous dates,
hormonal treatments, antecedent of irregular
cycling, and pseudopregnancy) (5,12,33).
Animals with CEH have normal blood and urine
tests (8). Haematology can show non regenerative
normocytic normochromic anaemia due to the
177
chronic inflammation and toxic effects that cause
suppression of the erythropoiesis in the bone
marrow (12,20,33). Other causes can be diapedesis
of erythrocytes towards the uterus because of the
inflammatory process, blood loss during surgery
(if it is the treatment of choice) and haemodilution
due to fluid therapy (34,41).
Most of the queens with pyometra show abnormal
white blood counts frequently characterized by
leukocytosis with neutrophilia and left deviation
with values than can oscillate from 20.000 up to
120.000/m1 (12,10,33,23), in approximately 66%
(14). Leukopenia can be present in around 5% of
coli
the cases (2,12).
Vaginoscopy is also recommended for direct
observation of the haemorrhgaic or mucopurulent
discharge (9) originating from the uterus, primary
or secondary hyperaemia, inflammation of the
cervix and vagina or any other pathologic process.
At the same time it is recommended to perform
cytology of the secretions to support the diagnosis.
The most common finding is the evidence of
abundant neutrophils blended with erythrocytes.
Leukocytes can show different states of karyorrhe-
xis and karyolysis (2,33). Endometrial cells can
also be found (2). Presence of bacteria is quite
rare, however this finding must be correlated with
culture and antibiogram to establish a proper treat-
ment (12,41). Samples can be taken directly from
uterine lumen after ovariohysterectomy (OVH) or
from secretions from the cranial vagina if an
immediate sample is required or the medical
management has been chosen (2).
The biochemical profile usually does not show
huge abnormalities. Hyperglobulinaemia can be
present in 30-60% of the cases (2,5,12). In cases
of sepsis and shock, it is also possible to find
hypoglycaemia due to increase of the consumption
of glucose, rapid glycogen storage waste and
decrease in gluconeogenesis (3,41). Additional
non-specific manifestations like hypokalaemia and
azotaemia are generally due to hypovolaemia and
circulatory collapse. Hyperbilirrubinaemia and
increase of activity of the alkaline phosphatase are
found in about 12% of the cases, and are probably
due to a hepatic perfusion decrease or toxicity,
secondary to sepsis (12,20). However, most of the
cases are self-limited and are solved after starting
the supportive treatment (12,41). Hyperproteinae-
mia and hyperfibrinogaenemia can be found due to
dehydration or inflammatory process.

Reported findings in the urinalysis are proteinuria
and isostenuria (20). Urine collection must be car-
ried out carefully because of the high probability
of sample contamination or favor urinary tract
infection due to catheterization. To avoid uterine
perforation, cystocentesis should be performed
only by ultrasound guided technique (2).
In most of the cases blood progesterone levels are
increased (>5 ng/ml) because of corpora lutea
activity, although it has been reported that it is
possible that the plasma progesterone is not
required to induce or to maintain pyometra. In
other words it is possible to find normal levels
(4,9).
Radiology of the abdomen can confirm the uterine
enlargement: the x-rays will identify an uterus that
emerges from the pelvis as dilated, showing a
homogeneous and sometimes sacculiform structure
with dorsal and cranial displacement of the small
intestine (1,12,6,26,33,23,36). Cases of closed-
cervix pyometra cases with pregnancy of the
contralateral horn can be detected by x-rays (33).
In earlier pregnancy, ultrasound is always recom-
mended because the radiographic appearance of
pyometra and the gravid uterus are essentially
identical until fetal calcification is detectable in
approximately 40 days' gestation (5,12,13). Care
must be taken with organ overimposition that can
confuse diagnosis (i.e. urinary bladder) or in the
cases of slight pyometra that can be more difficult
to detect (23). .
Pneumoperitoneum certainly improves radiograph
quality, but any procedure that involves abdominal
manipulation (punction) should be avoided due to
the risk of perforation of distended uterus with
weakened walls (33).
In most cases ultrasound is preferred because in
this way pregnancy can be easily differentiated
from a big uterus filled with anechoic or hypoe-
choic fluid (5,6,9,10,12,26,36,42) with a contou-
red or straight shape containing small liquid
accumulations (<5mm) in the walls. Pregnancy in
cats can be detected ultrasonographically after 21
day in cats (8). Sometimes it is possible to identify
"spotted" echogenicity with multiple cysts from 1
to 5 mm in the uterus. These can be thickened
endometrium, small mucous, hemorrhagic
necrotic tissue accumulation or wall enlargement
(5,17). Differentiation should be made between
uterine horns and intestinal loops, although
would result in a very different symptomatology
178
(5). Furthermore, if pregnancy is detected, fetal
viability must be performed. Ascitic fluid
suggesting possible uterine rupture, can be
identified in a small percentage of cats with
pyometra (13).
Treatment
Treatment should be rapid and aggressive, because
septicaemia and endotoxaemia can develop at any
time (2,12,13). When pyometra is suspected, a
detailed and careful clinical examination is needed.
Similar as in dogs, pyometra in cats is considered
as an emergency (41). Treatment includes correcti-
on of fluid deficits, proper administration of
antibiotics against bacterial organisms and removal
of infected uterine contents. The latter can be
achieved surgically by OVH or medically by
PGF2c, (10,12).
No matter which option is choosen, medical or
.
surgical, fluid therapy should be accurate to
replace deficits (acid base and electrolytic, mainly
potassium), correct azotaemia and maintain ade-
quate tissue perfusion. In most cases, it is recom-
mended to administer glucose endovenously, even
in the post-operative period so that the risk of
hypoglycaemia is minimized. Such situation is
very common in the sick cat. Antibiotics should be
choosen according to the culture sensitivity (2,12,
20).
While waiting for the results of the tests of the
antibiotic sensitivity, wide broad bactericide
antibiotics against the most common bacteria (E.
coli) is recommended (2,12). This includes
ampicillin (20 mg/kg IV, IM, SC or PO, TID),
trimethoprim sulfonamide (15-30 mg/kg PO, SC
or IV, BID), clavulanate + amoxicillin (20-25
mg/kg PO, SC, IM or IV, TID), enrofloxacin (5
mg/kg IM or SC, SID) and cephalosporins (i.e.
cephalexin, 20-40 mg/kg, PO, TID or cephalotin,
15-25 mg/kg IV, IM or SC, TID) (2,12,13,17).
The use of other antibiotics (tetracyclines,
chloramphenicol and aminoglycosides) are also
efficient in the treatment of E. coli, but they are
poorly tolerated by some cats (39). E. coli can be
resistant to ampiciline, cephalotine and tetracycli-
nes. Enrofloxacin other fluorquinolones can reach
higher therapeutic levels in the uterus as well as in
or other fluorquinolones (2).
The decision to try medical or surgical therapy is
based on the physical status and breeding capacity
it of the queen. The surgical approach should be
considered if a critical or unstable situation exists
 179
due to septicaemia, shock, azotaemia, if there are
radiographic evidence of uterine rupture or perito-
nitis or mummified fetal remaining, because the
removal of the infected material becomes necessa-
ry. Medical treatments to empty the uterus can last
several days and thus complicate the situation and
the pharmacologic effects can be deleterious for a
patient severely affected and must only be
performed in those queens with minimal systemic
compromise and high reproduction value (9).
Systemic antibiotic therapy alone or combined with
vaginal antiseptic showers, is not effective in
solving the clinical problems (5,8,17).
Ovariohysterectomy
This surgical therapy has been considered to be the
treatment of choice as it is curative per se (5,9,12,
13,17,28,33,37). However, despite its safety, it
has been associated with mortality and morbidity
rates despite its safety, sepsis being the most
common cause of death rather than surgical techni-
ques or anaesthetic protocols. Surgical techniques
and anaesthesia should be carried out very careful-
ly to minimize the mortality and morbility. It has
been demonstrated in dogs that the inability to
diminish azotaemia prior to surgery has been
associated with higher mortality. This rate has
been calculated in 5 to 8% of the cases (2,12,14).
Lethargy, vomiting, fever and postoperative anore-
xia are the most common postoperative morbidi-
ties, which can reach up to 20% (12,14.15,17).
Surgical techniques are reviewed elsewhere exten-
sively (34,38,41). In stump pyometra, excision is
recommended (9) with examination of the ovarian
stumps for presence of retained ovarian tissue
(14). Other techniques documented are hysterecto-
my and uterine drainage tubes (5), although these
procedure are not recom-mended (8).
Medical treatment
The medical approach is carried out with natural
prostaglandin F2a. It can be used in queens that
have value in reproduction programs, are in stable
health status (without sepsis or peritonitis suspici-
on) and have open-cervix pyometra (2,5,10,12,
21). In spite of the fact that there has been a
certain grade of success of this method in dogs
with closed-cervix pyometra (25-34%), in general
it has not been successful in cats (2). Medical
therapy is recommended for elderly patients becau-
se of higher surgical and anaesthetic risk as far as
they are concerned (10). However, in some refe-
rences it is mentioned that this is not useful and
must be avoided in geriatric patients older than 8
years (9). It is important to rule out fetal presence
before treatment, because of the drug's abortive
effects: PGF2a can cause abortion in queens up to
the 40th day of pregnancy due to myometrial con-
traction and fetal expulsion. In advanced pregnacy
this would not need to happen because of the con-
current placentary progesterone production. On the
other hand, one author claims that this production
only occurs after the 45th day (5).
Mechanisms of action of PGF2a include uterine
contractions (myoepitheliurn contractions), opening
of the cervix and functional arrest of corpora lutea
or even luteolysis (5,33, 39,40). The sensitivity of
corpora lutea to the prostaglandin effects depends
on the age of the corpora lutea, the dosage of
prostaglandin, and the duration of treat-ment (13).
This response is idiosyncratic in every individual
queen. When administered early in diestrus,
PGF2a is not luteolytic in the queen (14). After
PGF2a administration, plasma progesterone
concentration decreases. This is attributed to
luteolysis or esteroidogenesis inhibition through
the exhaustion of free intracellu-lar cholesterol and
this effect is more pronounced when diestrus
finishes. In queens, therapeutic dosage of PGF2a
does not always cause luteolysis (13). Uterine
biopsies in queens with pyometra after treatment
have not been studied, but a signifi-cant effect on
the endometrium is not expected and the
underlying CEH does n ot disappear. Moreover,
pyometra can show recurrence after treatment with
PGF2a. In one study 14% of the queens treated
with PGF2a showed recurrence of pyometra.
Therefore, is desirable to recommend castration as
soon as possible (10,36).
It has not been proven in cats completely, but
probably prostaglandins cause myometrial contrac-
tions, which evacuate uterine contents. This
myotonic effect increases intrauterine pressure and
in women a progressive reduction of prostaglan-
dins receptors in the endometrial smooth muscle
toward the cervix has been determined (5).
Contraction of the uterus could result in expulsion
of the contents (5). PGF2a administration is contra-
indicated in pre-existent uterine rupture It can
predispose uterine rupture in queens with closed-
cervix pyometra (12). In women and rabbits there
has been observed a relaxation of the uterine
 180
cervix, but this has not been seen in cats.
Patients undergoing such therapy must be hospita-
lized according to their clinical status (5,8,40).
The treatment protocol with PGF2a is from 0,1 to
0,25 mg/kg SCT SID or BID. The dose depends
mainly on clinical signs. The volume of vulvar
discharge should increase as the uterus empties.
The discharge usually becomes less purulent and
more mucoid or hemorrhagic as treatment conti-
nues (13). Treatment must continue till the vulvar
discharge stops and the uterus returns to its normal
size, and this can be expected between 3 to 5 days
after treatment.
Treatment can be continued for more than 5 days
if the uterus is not yet empty (13) and must only
be performed if the clinical status is adequate (5).
Minimal therapeutic doses in queens have not been
established, but it has been observed that the
response to higher doses (0,25 mg/kg BID (14) is
not more beneficial than that to the normal, gene-
rally accepted and recommended dose of 0,1
mg/kg SID during 5 to 7 days (5,12,36,40). Care
must be taken to give adequate antibiotic and fluid
therapy (39). Other reports suggest doses about 50
pg/kg TID or QID or another of 200 to 500 pg/kg
SID or BID.
Doses of 0,5 or 1 mg/kg SC BID, once in two
days after day 40 of pregnancy, or five daily IM
injections of 2 mg per cat after day 33 of pregnan-
- cy, have been reported to result in complete luteo-
lysis and abortion within 1 to 6 days after the first
injection, suggesting that such treatment also may
be effective for inducing luteolysis in pyometra
(14). Because of little information available on
induction of luteloysis in the cat with pyometra
and the risk of the use of luteolysis inducing
drugs, the main aim must not be luteolysis but
uterine evacuation, which is usually very beneficial
in the cat (14).
Natural PGF2 is the only prostaglandin which has
been evaluated for the use in felines (5). Other
more potent prostaglandins (i.e. synthetic
substances like closprostenol) have not been
evaluated and can not substitute natural
.
prostaglandins. Their use in cats could end in a
fatal response because the safe and effective dose
has not been established (2,12).
In queens with open-cervix pyometra, the progno-
sis of recovery acute disease and future pregnancy
viability is excellent. The rate of short term
success is 82 to 100% (5,12), which is achieved
when therapy has been finished after improvement
of most of the clinical signs. Follow-up must be
done 2 weeks after discharge. No or only very
little vaginal secretion and absence of uterine
enlargement confirmed by imagenologic tests
should be observed (5). Most of the treated queens
(95%) return to normal estrous cycles and
successful mating resulting in pregnancy (nearly
85%) (12,13,14,39). In those patients treated with
prostaglandins, care must be taken when breeding
the next estrous so that possible complications can
be avoided when consecutive effects of progestero-
ne in a no gravid uterus are present (2,5).
It is suitable to carry out the OVH immediately in
those patients with close-cervix pyometra, where
the opening does not take place after some days of
treatment and the patient's condition deteriorates
(40).
At therapeutic range, PGF2a can cause some side
effects in most of the queens. All these effects are
dose dependent and obey physiologic actions of the
endogen prostaglandins and include vasodilatation,
haemostasis, pulmonary vasoconstriction and bron-
chodilation, gastroenteric tract secretion, increase
in renal blood flow and glomerular filtration rate,
inflammation, hyperalgesia, fever, smooth muscu-
lar activity (myometrium, gastrointestinal tract,
urinary bladder, tracheobronchial tract) (5). The
signs include vocalization, panting, restlessness,
salivation, urination, defaecation, tenesmus, diar-
rhoea, emesis, mydriasis, grooming, lordosis and
kneading (2,5,12,13,40).
These effects can occur soon after administration,
but cease after 1 hour (39). Signs decrease in
severity and intensity in the subsequent applicati-
ons. That is the reason not to interrupt the treat-
ment at the beginning (2,5,12). Uterine rupture or
leakage of the intraluminal contents into the abdo-
men via the uterine tubes is possible (13,33). For
several reasons, this could occur more often in
cats than in dogs: 1)in, cats, uterine rupture with
generalized peritonitis can occur before treatment
(in about 4% of the cases), 2)feline pyometra is
sometimes seen in conjunction with uterine torsi-
on, a condition that would greatly increase the
chance of rupture and finally, the uterine exudate
found in cats with pyometra is occasionally very
viscous and hard to be expelled.
LD50 in cats has not been reported as in dogs
(5,13 mg/kg) (38). Overdose from 1 to 5 mg/kg,
can produce ataxia and severe respiratory distress,
but not death (13).
 181
Other drugs like oxytocine, ergometrina and estro-
gens have been used with limited responses (37).
Conclusions
Feline CEH-pyometra complex behaves differently
compared to the canine counterpart, but there are
some similarities in the clinical signs and
diagnostic tools. There have been carried out some
studies to achieve a histological classification,
which is very important to clarify different stages
of the disease.
The disease can be treated successfully medically,
although to avoid secondary effects of the disease
and adverse effects of therapeutic prostaglandins,
the ideal approach is still the surgerical therapy.
References
1. Agut A, Sanchez-Valverde MA, Lasaosa JM and Laredo
FG. Radiodiagnóstico en pequefios animales, 1st edition,
1992. Interamericana-McGraw-Hill, Mexico D.F. p. 296.
2. Barsanti JA. Genitourinary Infections. In: Infectious
diseases of the Dog and Cat. 2nd edition. 1998. Edited by
C.E. Green. W.B. Saunders Company, Philadelphia.
p. 643-644.
3. Brady CA, Otto CM, Van Winkle Ti, King LG. Severe
29 cases (1986-1998). Journal of the
sepsis in cats:
American Veterinary Medical Association 2000; 217:
531-535.
4. Davidson AP, Feldman EC and Nelson RW. Treatment of
pyometra in cats, using prostaglandin F2 alpha: 21 cases
(1982-1990). Journal of the American Veterinary Medical
Association 1992; 200: 825-828.
Davidson AP. Medical treatment of pyometra with
5.
prostaglandin F2a in the bitch an queen. In: Current
Veterinary Therapy, XII, 1995. Edited by J.D. Bonagura
and R.W. Kirk. W.B. Saunders Company, Philadelphia.
p. 1163-1165.
6. Dennis R, Kirberger RM, Wrigley RH and Barr FJ.
Handbook of Small Animal Radiological Differential
Diagnosis, 1m edition, 2001. WB Saunders Company,
Philadelphia, p. 201-202.
7. Dow C. The cystic hyperplasia-pyometra complex in the
cat. Veterinary Record 1962; 74: 141.
8. Feldman EC, Nelson RW. Canine and Feline
Endocrinology and Reproduction, 2nd edition, 1996. W.B.
Saunders Company, Philadelphia. p.740-768.
9. Goldston RT, Hoskins JD. Geriatrics & Gerontology of
the Dog and Cat, ln edition, 1997. W.B. Saunders
Company, Philadelphia. p. 411-412.
10. Harvey M. Alterations in the non pregnant female. In:
Manual of Small Animal Reproduction & Neonatology,
1m edition, 1998. Edited by G.M. Simpson, G.C. England
and M. Harvey. British Small Animal Veterinary
Association (BSAVA). Gloucestershire. p. 47-68.
11. Holt BS, Bergstrom A, Lagerstedt AS, Karlstam E,
Englund L and Báverud V. Characterization of the bacte-
rial population of the genital tract of adult cats. American
Journal of Veterinary Research 2003; 64: 963-968.
12. Jhonson CA. Female reproduction and disorders of the
female reproductive tract. In: The Cat. Diseases and
Clinical Management, vol. 2, 2nd edition, 1994.
Edited by R. Sherding. Churchill Livingstone, New York.
p. 1855-1876
13. Johnson CA. Medical Management of Feline Pyometra.
In: Current Veterinary Therapy, XI, 1992. Edited by J.D.
Bonagura and R.W. Kirk. W.B. Saunders Co,
Philadelphia. p. 969-971.
14. Johnston SD, Root MV and Olson PN. Canine and Feline
Theriogenology, lst edition, 2001. W.B. Saunders
Company. Philadelphia. p. 396-405 and p. 447-471.
15. Kenney KJ, Matthiesen DT, Brown NO and Bradley RL.
Pyometra in cats: 183 cases (1979-1984). Journal of the
American Veterinary Medical Association 1987; 191:
1130-1132.
16. Lawler DF, Johnston SD, Hegstad RL, Keltner DG and
Owens SF. Ovulation without cervical stimulation in
domestic cats. Journal of Reproduction and Fertility.
Supplement 1993; 47: 57-61.
17. Lawler DF, Johnston SD. Complications of the Non Ovu-
latory Copulation in the Queen. In: Current Veterinary
Therapy, XII, 1995. Edited by J.D. Bonagura and R.W.
Kirk. W.B. Saunders Co, Philadelphia. p. 1166-1167.
18. Little S. Feline Reproduction and Breeding Management.
Veterinary Medicine 2001; 96: 549-555.
19. Little, S. Uncovering the cause of infertility in queens.
Veterinary Medicine 2001; 96: 557-568.
20. Lucas SS, Lima de Oliveira AL and Wallau JE. Pyometra
in Dogs and Cats: Review of 103 cases. Revista da
Faculdade de Zootecnia, Veterinaria e Agronomia
Uruguaiana 2000; 7: 99-103.
21. Macintire DK. Emergencies of the Female Reproductive
Tract. Veterinary Clinics of North America: Small
Animal Practice 1994; 24: 1173-1188.
22. Munson L, Gardner IA, Masson RJ, Chassy LM and Seal
US. Endometrial hyperplasia and mineralization in zoo
felids treated with melengestrol acetate Contraceptives.
Veterinary Pathology 2002; 39: 419-427.
23. Murdoch DB. Abdomen. In: Manual of Small Animal
Diagnostic Imaging, 1m edition, 1997. Edited by R. Lee.
British Small Animal Veterinary Association (BSAVA).
Gloucestershire. p. 111-114.
24. Nomura K, Koreeda T, Kawata M and Shiraishi Y. Vagi-
nal atresia with transverse septum in a cat. Journal of
Veterinary Medical Science 1997; 59: 1045-1048.
25. O'Neill LL, Burkhard MJ and Hoover EA. Frequent peri-
natal transmission of feline immunodeficiency virus by
chronically infected cats. Journal of Virology 1996; 70:
2894-2901.
26. Owens JM and Biery DN. Radiographic Interpretation for
the Small Animal Clinician, 1999. Williams and Wilkins,
New York. p. 287-288.
27. Romagnoli S and Concannon PW. Clinical Use of Proges-
tine in Bitches and Queens: A review. In: International
Veterinary Information Service (www.ivis.org), 2003.
Edited by P.W. Concannon, G. England, J. Verstegen III
and C. Linde-Forsberg. New York.
28. Romagnoli S. Clinical approach to infertility in the queen.
Poceedings of the ESFM Feline Congress, Stockholm (S),
September 2002.
29. Root MV. Biologia felina: reproducción. ReproducciOn
felina. Anatomia y Fisiologia Normal de la ReproducciOn.
Anormalidades Reproductivas en la Gata. Felinia.
www.felinia.org/f3/reproduccion/reproduccion.htm
 182
30. Rosendal S. Micoplasmic Infections in Dogs and Cats. In:
Current Veterinary Therapy, XII, 1995. Edited by J.D.
Bonagura and R.W. Kirk. W.B. Saunders Company,
Philadelphia. p. 328-330.
31. Sanchez AE and Silva ME. Biology of pregnancy in the
domestic cat (Felis catus). Archivos de Medicina
Veterinaria 2002; 34.
32. Schulman J and Levine SH. Pyometra involving uterus
masculinus in a cat. Journal of the American Veterinary
Medical Association. 1989; 194: 690-691.
33. Sorribas CE. Reproducción en los Pequenos Anima les,
1995, la ediciOn. Intermédica, Buenos Aires. p 86-90.
34. Stone EA. El Otero. In: Texto de Cirugia de los Pequerios
Anima les, vol. 2. 1st edition, 1989. Edited by D.H.
Slatter. Salvat Editores, Barcelona. p. 1733-1744.
35. Tamada H, Kawate N, Inaba T and Sawada T. Long-term
prevention of estrus in the bitch and queen using
chlormadinone acetate. Canadian Veterinary Journal
2003; 44: 416-417.
36. Thrall DE. Textbook of Veterinary Diagnostic Radiology.
2nd edition, 2004. W.B. Saunders Company, Philadelphia.
p. 494-499.
37. Toniollo GH, de Faria D, Lega E, Matista CM and
Nunes N. Pyometra in feline species - Report of a case in
Panthera onca. Brazilian Journal of Veterinary Research
and Animal Science 2000; 37.
38. Van Sluijs FJ. Atlas de Cirugia de los Pequerios
Anima les. 1993. Masson-Salvat, Barcelona. p. 82-83.
39. Verstegen JP. Pharmacological Management of the
Reproduction in the Cat In: Manual of Small Animal
Reproduction & Neonatology,15` edition, 1998. Edited by
G.M. Simpson, G.C. England and M. Harvey. British
Small Animal Veterinary Association (BSAVA).
Gloucestershire. p. 297-305.
40. Von Reitzeinstein M, Archbald LF and Newell SM.
Theriogenology Question of the Month. What are the
differential diagnoses for uterine enlargement in this
unmated cat? Pyometra, hydrometra or mucometra.
Journal of the American Veterinary Medical Association
2000; 216: 1221-1223.
41. White RN. Surgery of the Genital Tract. In: Manual of
Small Animal Reproduction & Neonatology, 1st edition,
1998. Edited by G.M. Simpson, G.C. England and M.
Harvey. British Small Animal Veterinary Association
(BSAVA). Gloucestershire. p. 231-266.
42. Yeager AE and Concannon PW. Ultrasonography of the
Reproductive System in the Bitch and the Queen. In:
Current Veterinary Therapy, XII, 1995. Edited by J.D.
Bonagura and R.W. Kirk. W.B. Saunders Company,
Philadelphia. p. 1120-1132.