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A 66-year-old woman was referred to the Gynecology department due to stress urinary incontinence. Menopausal since the age of 52, never used hormone replacement therapy and denied postmenopausal bleeding. Examination showed severe atrophy of the upper vaginal third without a clear identification of the cervix and an enlarged uterus. Transvaginal ultrasound suggested a voluminous hematometra and cervical dilation (Figure 1 a), further characterized by MRI (Figure 1 b).
Figure 1 Transvaginal ultrasound (a) and parasagittal MRI (b) showing enlarged postmenopausal uterus with moderate cavity distension and severe distended cervical canal. Both structures are filled with hematic content. Maximum diameter of the uterine cavity - 32 mm; maximum diameter of the endocervical canal - 71 mm. No signs of focal lesions nor neoformation masses were recognized. Lesions probably secondary to upper vaginal stenosis.
Figure 2 Office hysteroscopy details: a 5Fr scissors was used to perform a star-shaped incision in the exact location of the external cervical os, identified by the “blue behind the white” sign and allowed the passage into the cervical canal, creating an adequate external cervical os, which drained one liter of old blood. Cavity inspection and biopsy revealed atrophic endometrium.
The patient underwent an office hysteroscopy with vaginoscopic approach. A complete obliteration of the external cervical os was observed (Figure 2). Stenosis was solved using endoscopic scissors and one liter of old blood was evacuated (Figure 2). The procedure was completed without complications and the patient remains under surveillance, with no recurrence of the clinical condition.
This case demonstrates a successful management of a voluminous hematometra and cervical stenosis with office hysteroscopy with vaginoscopic approach without anesthesia. This minimally invasive procedure represents the gold standard approach in these settings1),(2. With direct visualization, it is possible to overcome the stenosis while reducing the risk of injury3.
Author’s contribution
António de Pinho has contributed substantially to the collection and analysis of data, writing of the manuscript and final approval of the version to be published. Catarina Estevinho and Cristina Oliveira have contributed substantially to the critical review of the manuscript and final approval of the version to be published.
Statement of ethics
The authors declare that the procedures were followed according to the regulations established by the Clinical Research and Ethics Committee and to the Helsinki Declaration of the World Medical Association updated in 2013.
The authors declare having followed the protocols in use at their working center regarding patients’ data publication.
