Many patients might present with less frequent or scanty menstrual flow. Others may present with lack of menstruation altogether. Infrequent menstruation or oligomenorrhoea is always hormone related. It will be discussed in a different chapter in this website in the near future. This chapter will concentrate on absent or scanty menstruation following endometrial infection or trauma.
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Tuberculosis is the only infection related to reduced or absent menstrual loss. All other infections cause endometritis with more or irregular uterine bleeding.
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Trauma to the endometrium could follow such conditions as:
These operative procedures with superimposed infection could lead to adhesions formation between the denuded basal endometrial areas. However in most cases a pregnancy usually precedes the onset of such a problem. More adhesions follow evacuation of a missed than incomplete miscarriage.
Traumatic hypomenorrhoea or amenorrhoea could be due to:
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Complete or partial obstruction of the uterine cavity with adhesions
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Apical adhesions covering the area of the internal cervical os only
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Damage to the basal endometrial layer without any adhesions formation
Management
History could give a clue as to the nature of the problem especially if the symptoms followed an operative procedure. On the whole systemic and pelvic examinations would be unremarkable. However transvaginal scanning could show:
Using saline infusion sonohysterography could confirm and show the extent of intrauterine adhesions. The triangular sonolucent normal cavity would be replaced by irregular bright areas denoting the adhesions site.
The 3 ultrasound pictures shown above respectively depict:
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A thin indiscriminate endometrium despite the presence of a large follicle.
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A sagittal view of a uterus with intrauterine adhesions disrupting the sonolucent cavity after SIS.
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A rendered 3D coronal view of a uterus with intrauterine adhesions occupying most of the left side of the cavity after instillation of saline (SIS).
The last hysteroscopic photograph shows many intrauterine adhesions as well as a large submucous fibroid.
Once a diagnosis is confirmed surgery would be the only viable option depending on the patients wishes. The surgical objectives would be:
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restoration normal endometrial cavity
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prevent recurrence of adhesions
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resumption of menstruation
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facilitate intrauterine pregnancy
These objectives could be fulfilled in many but not all patients, depending on the severity of the condition. Hysteroscopic incision of these adhesions should be attempted under laparoscopic guidance. Scissors could be used with the benefit of avoiding further damage to the endometrial cavity if a resectoscope is used instead. However it takes longer time with scissors to finish the job and in many occasions only thermal excision is possible due to the thickness of the scar tissues.
The above 6 hysteroscopic photographs show excision of a large band of intrauterine adhesions. The patient presented with hypomenorrhoea and cyclic pain after her second open myomectomy. She resumed menstruating normally after surgery .
Patients should be made aware of the possible risks involved including:
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perforation of the uterus and creation of false passages
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thermal damage and lack of menstruation despite successful restoration of the cavity
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infection leading to partial or complete recurrence of the adhesions
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bleeding immediately after surgery due to myometrial injury or delayed bleeding following secondary infection
It is usual to insert an IUCD or a Foley’s catheter into the cavity following its successful restoration. The coil could be left for few months but the catheter is removed within 10 days. As well oestrogen in the form of premarin 2.5 mg every day is prescribed for few weeks to encourage regeneration of the basal endometrium. This should be followed by a progestogen withdrawal bleeding in due course.
Treatment of such cases could be difficult and the final outcome might be disappointing depending on the extent of the initial endometrial damage. Despite successful restoration of the uterine cavity the following could occur:
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Menstruation might not follow
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The patient might fail to conceive or have recurrent miscarriages
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Morbid implantation of the placenta might occur leading to placenta praevia, acreta, increta or percreta |