Treatment of Hematometra
Hematometra is treated primarily by relieving the obstruction causing blood accumulation in the uterine cavity, most commonly through cervical dilation and drainage, with the specific approach depending on the underlying cause and severity of obstruction.
Initial Diagnostic Confirmation
- Confirm diagnosis with transvaginal ultrasound to visualize uterine distention and identify the level of obstruction (cervical versus vaginal) 1, 2
- Assess for underlying causes including cervical stenosis from prior procedures (Manchester repair, endometrial ablation/resection), congenital anomalies, or cervical atresia 1, 3, 4
- Evaluate symptom severity including cyclic or acute abdominal pain, urinary retention, and presence of pelvic mass 1, 2, 5
Primary Treatment Approach
For Acquired Cervical Stenosis (Most Common in Adults)
- Perform cervical dilation under anesthesia as the first-line treatment 2, 5
- Use graduated Hegar dilators to achieve adequate cervical patency (typically to size 6 or greater) 5
- Drain accumulated blood once adequate dilation is achieved 2, 5
- Consider dilation and curettage (D&C) for complete evacuation if simple drainage is insufficient 2
For Cervical Atresia (Congenital or Severe)
- Ultrasound-guided cervical fenestration represents a minimally invasive approach for complete cervical atresia 4
- Technique involves passing a spinal needle through the atretic cervix under combined vaginoscopy and dynamic ultrasound guidance 4
- Balloon dilatation (using esophageal balloon dilator up to 10mm) can be performed over a guidewire after initial fenestration 4
- Temporary catheter placement (Foley catheter size 24) for 1 week helps maintain patency 4
Alternative Drainage Methods
- Ultrasound-guided puncture and drainage can be used as a temporizing measure or when cervical approach is not feasible 3
- Hysteroscopy with fluid medium provides both diagnostic and therapeutic options 3
Post-Procedure Management
- Monitor for recurrence with follow-up ultrasound before subsequent menstrual periods, as re-stenosis is common 4
- Repeat dilations may be necessary, particularly in cases of cervical atresia where multiple sessions (2-3 or more) are often required 4
- Discontinue contributing medications such as depot medroxyprogesterone acetate if implicated 2
- Consider definitive surgery (vaginal hysterectomy) in postmenopausal women or cases refractory to conservative management 3
Important Clinical Pitfalls
- Do not mistake post-procedural amenorrhea for menopause in women who have undergone Manchester repair or endometrial ablation, as this can lead to gradual hematometra accumulation 1
- Cervical stenosis after endometrial ablation/resection is an uncommon but recognized complication that requires prompt recognition 3
- Recurrent stenosis is common after initial treatment, particularly in cervical atresia cases, requiring ongoing surveillance and potentially multiple interventions 4
- Warn patients undergoing endometrial ablation about the possibility of hematometra development so symptoms can be addressed rapidly 3