Hematometra After Endometrial Ablation: Clinical Presentation
Yes, hematometra can absolutely present with intermittent dark vaginal discharge or bleeding followed by yellowish discharge in a patient who had endometrial ablation years ago, and this presentation should raise immediate concern for this specific post-ablation complication.
Understanding the Pathophysiology
Hematometra is a well-recognized long-term complication of endometrial ablation that occurs when intrauterine scarring and contracture obstruct bleeding from persistent or regenerating endometrium behind the scar 1. The clinical presentation you describe is characteristic:
- Dark vaginal discharge/bleeding: Represents old, trapped menstrual blood that has been obstructed within the uterine cavity and eventually finds a path of drainage 2, 3
- Yellowish discharge: May represent infected or degraded blood products, or could indicate superimposed infection of the obstructed cavity 3
- Intermittent pattern: Occurs because the obstruction may be partial, allowing periodic drainage when pressure builds sufficiently 1, 4
Diagnostic Approach
Transvaginal ultrasound is the first-line imaging study to evaluate for hematometra in symptomatic post-ablation patients 2. Sonographic findings in symptomatic patients after endometrial ablation include:
- Fluid collection within the uterine cavity (hematometra) 2
- Residual islands of functioning endometrial tissue, either alone or in combination with hematometra 2
- Cornual hematometra (blood trapped in the uterine horns) 1
In one transvaginal ultrasound study of symptomatic post-ablation patients, 2 of 7 had hematometra, and 4 had residual functioning endometrial tissue alone or combined with hematometra 2.
Critical Clinical Pitfalls
The incidence of post-ablation complications like hematometra is likely understated because many clinicians are not educated about these specific findings 1. Key points to avoid missing this diagnosis:
- Do not dismiss cyclic or intermittent symptoms in post-ablation patients as "normal" 3, 1
- Recognize that endometrial ablation creates scarring that can obstruct menstrual flow from any remaining functional endometrium 1
- Consider that yellowish discharge may indicate infection complicating the obstructed cavity, requiring more urgent intervention 3
Management Considerations
Treatment options for confirmed hematometra include 4:
- Ultrasound-guided puncture and drainage
- Hysteroscopy with fluid medium to relieve obstruction
- Hysterectomy in refractory cases
If repeat endometrial ablation is considered, it should only be performed by a hysteroscopic surgeon with direct visualization of the cavity, and patients must be counseled about increased complication risks 5.
Additional Differential Considerations
While hematometra is the primary concern, other post-ablation complications that can present with abnormal discharge include 3, 1:
- Postablation tubal sterilization syndrome (if patient also had tubal ligation)
- Infection of the uterine cavity
- Delayed diagnosis of endometrial pathology behind the scar
The key message: Any symptomatic bleeding or discharge pattern in a post-ablation patient warrants transvaginal ultrasound evaluation to rule out hematometra and other structural complications 2, 3.