Uterine Abnormalities

Trauma to and/or infection of the uterine lining (endometrium) may lead to the formation of intrauterine adhesions or destruction of the endometrial lining. Intrauterine adhesions are defined as scar tissue inside the uterine cavity.

The principle cause of intrauterine adhesions is trauma to the uterine cavity. This may occur following dilation and curettage (D&C), an outpatient surgical procedure during which the cervix is dilated and the tissue contents of the uterus are emptied. D&C may be performed for excess uterine bleeding after childbirth, pregnancy termination, or other gynecological conditions. Less commonly, prolonged use of an intrauterine device (IUD), infections of the endometrium (endometritis), and surgical procedures involving the uterus (such as removal of fibroids) may also lead to the development of intrauterine adhesions.

Women with intrauterine adhesions may have no obvious problems. Many patients, however, may experience menstrual dysfunction in the form of absent, light, or infrequent menstruation. Also, they may be unable to achieve pregnancy, or experience recurrent miscarriages. Less commonly, pelvic pain or dysmenorrhea (painful menstrual periods) may be present. Diagnosis: Hysterosalpingography (HSG), an x-ray procedure, is a common method used to diagnose intrauterine adhesions. During an HSG, a solution is injected into the uterus to illustrate the inner shape of the uterus and determine if the fallopian tubes are open. Hysteroscopy is also used to diagnose intrauterine adhesions. This is a procedure in which a thin, telescope-like instrument is inserted through the cervix to allow direct visualization of the uterine cavity. Although HSG is a useful screening test, hysteroscopy is the most accurate method of evaluating intrauterine adhesions. Both HSG and hysteroscopy can be performed in an office setting without general anesthesia.

Surgical removal of intrauterine adhesions with hysteroscopic guidance is generally recommended. Following removal of the adhesions, many surgeons recommend temporarily placing a device, such as a plastic catheter, inside the uterus in an effort to keep the walls of the uterus apart and prevent adhesions from reforming. Hormonal treatment with estrogens and progestins, and non-steroidal anti-inflammatory medications, are frequently prescribed after surgery to lessen the chance of adhesion reformation.

Reproductive outcome appears to correlate with the type and extent of the adhesions. After treatment, patients with mild to moderate adhesions have full-term pregnancy rates of approximately 70 to 80 percent, and menstrual dysfunction is frequently alleviated. Alternatively, patients with severe adhesions or extensive destruction of the endometrial lining may only have full-term pregnancy rates in the 20 to 40 percent range after treatment. Women with extensive damage to the endometrium unresponsive to conventional therapy by hysteroscopy may be offered gestational surrogacy.

Uterine Fibroids are abnormal masses of smooth muscle tissue that are located in and around the uterus or womb and sometimes the cervix. Fibroids originate from the smooth muscle cells within the myometrium or wall of the uterus. In most cases, fibroids are multiple, but occasionally a single fibroid are myomas or leiomyomas. It is estimated that uterine fibroids occur in every four to five American women. Usually, they develop when a woman is in her 30s or 40s, and become smaller after menopause. Often fibroids do not require treatment. However, they may cause excessive uterine bleeding, pain, a sensation of pressure, infertility, miscarriage, and premature delivery. Removing the fibroids surgically can usually correct these problems. However, there is a chance that additional fibroids will develop.

Women who experience abnormal uterine bleeding should be evaluated by a physician. A medical history, discussion of possible contributing factors, and a detailed physical exam are usually necessary. A variety of diagnostic techniques are available for determining the cause of abnormal uterine bleeding.

The doctor may recommend an endometrial biopsy , an office procedure, to examine a sample of the uterine lining to rule out abnormalities of the endometrium. Hysteroscopy is a useful procedure that allows visual inspection of the entire uterine cavity (Figure 2). It may allow the physician to identify specific areas within the endometrium which may be biopsied or removed with special instruments. Hysteroscopy may be performed under general anesthesia or as an office procedure. For more information on hysteroscopy, refer to the ASRM patient information booklet titled Laparoscopy and Hysteroscopy. In some circumstances, a dilation and curettage (D&C) may be recommended to further assess the endometrial tissue. D&C may also be recommended for control of persistent or heavy bleeding in women for whom other methods have been ineffective. Generally, however, a hysteroscopy is performed prior to the D&C. A variety of techniques is available to visualize the uterus and pelvic organs. Ultrasound is a procedure which uses high-frequency sound waves to produce a picture of the pelvic structures. This is the most commonly employed imaging method for the pelvic organs and does not involve the use of x-rays. Less commonly, computerized tomography (CT) and magnetic resonance imaging (MRI) can be used to depict a three-dimensional image of internal organs including the uterus, although these procedures are rarely needed to determine the source of abnormal uterine bleeding. Abnormalities of the endometrium may be detected by a hysterosalpingogram (HSG). This entails the slow injection of an iodine-containing solution into the uterine cavity under x-ray guidance, so that the contours of the endometrium and fallopian tubes can be visualized.

Laboratory studies also aid in diagnosing abnormal uterine bleeding. Often a blood test will be obtained to check for anemia or a blood clotting disorder. When structural disturbances of the reproductive tract have been ruled out, a blood test to measure pituitary hormones, such as prolactin, FSH, and thyroid hormones may be performed. If there is evidence of increased androgen (male hormone) levels, the likely cause is polycystic ovarian syndrome (PCOS). PCOS is often associated with irregular or heavy menstruation. Additional tests of the liver, kidney, pancreas, and other major organs may be useful, depending upon each woman’s medical history. Laboratory studies for abnormal uterine bleeding will be based on the physician’s clinical judgment as to the underlying cause of the bleeding.

The individual therapy recommended will be tailored to the specific cause of abnormal bleeding. Structural abnormalities of the reproductive tract such as fibroids, polyps, or scar tissue can often be treated with hysteroscopy. Surgical instruments can be inserted through the hysteroscope to remove or correct structural abnormalities within the uterine cavity. Generally, patients can return to normal activities within 24 hours after a hysteroscopy. Serious complications are rare. Individuals who have adequate levels of estrogen but who do not ovulate can be effectively treated with synthetic progestins such as medroxyprogesterone acetate. Other progestins, including natural progesterone, are available as oral capsules, vaginal suppositories, or intramuscular injections, and are also effective for promoting complete shedding of the endometrial lining. In many instances, patients can be treated with low dose oral contraceptives (OCs), which provide both estrogen and progestins and promote regular menstruation.

Abnormal uterine bleeding is a common problem in reproductive aged women that can usually be corrected with surgery or medication. Surgery may be able to correct structural causes of abnormal bleeding. If there are no structural causes, medical therapy can often restore regular menstrual cycles. Whatever the cause of abnormal uterine bleeding, the many treatments available today can usually resolve the problem.