OP17.07: Menometrorrhagia due to impaired uterine drainage

Mechanical impairment of efficient uterine drainage may masquerade as prolonged active bleeding. Menstrual blood is normally expelled from the endometrial cavity over 3–7 days by a combination of uterine contractions and gravity. Menstrual drainage may be prolonged by one of five mechanisms: gravity, stiff uterus, cervical narrowing, intracavitary synechiae, or cervical diverticuli. In sharply retroverted retroflexed uteri (six cases) the effect of gravity is counterproductive, overwhelming fundo-cervical uterine contractions, resulting in prolonged spotty menses. A ‘stiff’ subcontractile uterus due to myometrial disease and/or high-dose progestins can result in hematometra without cervical stenosis: we have observed this with adenomyosis, and widespread non-cervical fibroids (11 cases). Cervical narrowing by true stenosis, immaturity, or masses may prolong drainage (16 cases). Pockets of menstrual fluid due to intracavitary synechiae (three cases), failed endometrial ablation (five cases) or gaping Cesarean section incisional scars (six cases) may also cause post-menstrual dribbling. Sonographic signs of poor drainage are hematometra, dependent hemoperitoneum or hematosalpinges, large Cesarean section defects and the presence of cervical masses. Cervical abnormality or non-distendable cavities are detectable at the time of a saline infusion study. The typical pattern of delayed drainage ranges from prolonged menses with tapering dark spotting to months of unremitting red then dark bleeding in the absence of anemia. Traditional cycling on OCPs appears to fail because the problem is mechanical: this is best treated with therapeutic amenorrhea.