From the Guidelines
Hydrometra in postmenopausal women should be promptly evaluated with transvaginal ultrasound to assess endometrial thickness, followed by endometrial sampling if thickness exceeds 3-4mm, as recommended by recent guidelines 1. The condition occurs when fluid accumulates in the uterine cavity due to cervical stenosis, which is common after menopause due to estrogen deficiency. Initial management includes:
- Transvaginal ultrasound to assess endometrial thickness
- Endometrial sampling if thickness exceeds 3-4mm, using techniques such as Pipelle or Vabra devices, which have high sensitivity for detecting endometrial carcinoma 1
- Cervical dilation may be necessary to drain the accumulated fluid and relieve symptoms If no malignancy is found, treatment options include:
- Vaginal estrogen therapy to improve cervical patency
- Hysteroscopic cervical dilation or placement of a small intrauterine device may be considered to maintain patency for recurrent cases In cases where malignancy is suspected or confirmed, referral to a gynecologic oncologist is essential, as the diagnostic accuracy of ultrasonography is lower than previously reported, with a sensitivity of 95% and 98% with a specificity of 47% and 35%, respectively, at a cut-off ≤4 mm and cut-off ≤3 mm 1. Patients should be monitored with follow-up ultrasounds at 3-6 month intervals initially to ensure resolution, and addressing symptoms such as pelvic pain, pressure, and vaginal discharge is important for patient comfort while the underlying cause is being treated. The use of hysteroscopy with biopsy should be reserved as the final step, if needed, in the diagnostic pathway of women with post-menopausal bleeding, as it is highly accurate and clinically useful in diagnosing endometrial cancer 1.
From the Research
Definition and Prevalence of Hydrometra in Postmenopausal Age
- Hydrometra is a common gynecological disease, especially in postmenopausal women, with a prevalence rate of 10.86% as observed in a study of 3,903 women 2.
- The prevalence of hydrometra is higher than that of other gynecological diseases, and it is often associated with advanced age and vaginitis as independent risk factors 2.
- A study of 300 postmenopausal women found that the incidence of hydrometra was influenced by the use of tamoxifen, with 49.3% of women taking tamoxifen developing hydrometra compared to 6.6% of those not taking hormone therapy 3.
Diagnosis and Management of Hydrometra
- Hysteroscopy is considered the gold-standard technique for the diagnosis and management of intrauterine pathology, including hydrometra, in postmenopausal women 4.
- Transvaginal ultrasound can be used to diagnose hydrometra, but it may not be sufficient to rule out endometrial cancer, and hysteroscopy or dilation and curettage (D&C) may be necessary for further evaluation 5.
- A study of asymptomatic postmenopausal women found that intrauterine fluid accumulation, which is often associated with hydrometra, is a common and mostly benign phenomenon that typically occurs in the late postmenopausal age subgroups 6.
Risk Factors and Predictive Value of Hydrometra
- Advanced age, vaginitis, and higher body mass index (>23.92 kg/m2) are independent risk factors for hydrometra, and abnormal vaginal bleeding is a high-risk predictive factor for gynecological tumors 2.
- A higher hydrometra volume (i.e., distance between the two layers of endometrium >4.75 mm) is also a predictive factor for gynecological tumors 2.
- Hormone replacement therapy appears to be a "protection" against the development of intrauterine fluid accumulation, which is often associated with hydrometra 6.