Case Study - Amenorrhoea and cervical stenosis

Dr Linda Miller discusses an unusual case of secondary amenorrhoea post-colposcopy.

Melanie, a 38-year-old graphic designer, presented complaining of dysmenorrhoea and, more recently, secondary amenorrhoea. She was otherwise well and not on any medication. She had had one son by normal vaginal delivery 10 years ago, and used condoms for contraception.

Her periods, which had always been regular and not particularly heavy, had become increasingly painful over the previous four months. The last had been painful and scanty. In the three days before the consultation she had had her usual premenstrual symptoms, but no bleeding per vagina.

She described general abdomino-pelvic discomfort with severe pains. On checking her past records it was noted that she had had a colposcopy and large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia 3 (CIN 3).

On examination Melanie had a normal uterus, with suprapubic tenderness, no rebound or guarding, a closed cervix, no cervical excitation, adnexal masses, or discharge and a negative urinalysis and pregnancy test.

Urgent pelvic ultrasound confirmed cervical stenosis and haematometra, and excluded ectopic pregnancy.

Treating CIN

Cervical stenosis is a recognised complication following treatments for cervical dyskariosis. It is defined either as cervical os narrowing preventing the insertion of a cotton swab or as difficulty or inability to perform a cervical brush smear.

Haematometra is a collection of menstrual blood in the uterine cavity secondary to cervical obstruction.

Retrograde menstruation and infertility can occur due to cervical obstruction.

Cervical stenosis also makes satisfactory follow up of CIN by smear tests and colposcopy more difficult.

Low-grade cervical dysplasia is followed with repeated smear tests and/or colposcopy. Moderate to severe dyskariosis - CIN 2-3 - is evaluated by colposcopy, directed biopsy and cone biopsy where appropriate.

Treatment may be by either excision or ablation using traditional (cold knife) cone biopsy, electric knife, or laser cone, large loop excision of transformation zone (LLETZ) with a loop electro surgical (LEEP) or laser technique, cryotherapy, laser or electrocoagulation diathermy.

Various studies have looked at the risks and outcomes of these procedures.

With excisional techniques, the whole cervical lesion can be excised and studied histologically, thus detect-ing micro-invasive carcinoma which can be missed by punch biopsy or ablative methods. However, ablative therapies have lower complication rates.

Complications

A study of 100 cold knife cone biopsy patients found a cervical stenosis rate of 3 per cent; the cure rate was 97 per cent after complete excision at 4.5 years. The procedure remains a valid option for CIN and micro-invasion of the cervix with a good cure rate and low risk of complications.

A US study of 557 LLETZ outcomes in the first 14 days found an overall complication rate of 9.7 per cent. The 0.6 per cent with major complications included one bowel perforation and one haemorrhage requiring surgery, and one case of prolonged chest pain.

There were 14 cases of abdominal pain, 26 of vaginal bleeding - seven of which needed treatment, six cases of vaginal discharge and one of bladder spasm. Most of the patients were aged 40 or less.

Conservative LLETZ treatment retains fertility but is associated with increased risk of premature rupture of membranes and preterm birth.

A French study attempted to compare outcomes of the three cone biopsy techniques. Incisions were less deep in the LEEP group. They concluded that LEEP excision should be the first treatment option.

The effectiveness of top-hat LLETZ (THLLETZ) was examined in a UK retrospective study of 513 patients which found that, although the newer top-hat method removed more cervical tissue, it was no better at ensuring that the cervical lesion was completely excised than conventional LLETZ.

There were more cases where follow up colposcopy and cytology were inadequate with THLLETZ than with LLETZ because 30.9 per cent of THLLETZ had cervical stenosis, compared with only 7.7 per cent with LLETZ. In France, cervical stenosis was found in 40 of 238 patients responding to follow up invitations three years after laser cone biopsy. Older patients were at higher risk of stenosis.

Complications

Stenosis risk was greater with deeper surgical excision, when preoperative junction was endocervical, when vaginal packing was necessary and when continuous laser mode was used. Stenosis risk was lower when HPV was present on biopsy, in smokers, and where surgical compress was placed on the excision site.

Post-puerperal women are at increased risk of cervical stenosis after conization for CIN and may present with prolonged lactation amenorrhoea.

Temporary cervical stents have been advocated to prevent cervical stenosis after cone biopsy in the past, but the practice did not become routine.

A systematic review found that vasopressin and tranexamic acid reduced perioperative bleeding. Elective haemo-static suturing had an adverse effect on blood loss, cervical stenosis and successful follow up, increasing the risk of amenorrhoea and dysmenorrhoea.

The review suggested that vaginal packing reduced post- surgical stenosis and improved successful follow up rates.

Routine investigation of secondary amenorrhoea usually includes either abdominal or vaginal ultrasound imaging. MRI is useful for imaging uterine cervical lesions and -together with histopathology - distinguishing between epithelial neoplasms, non-epithelial neoplasms and non-neoplastic diseases.

MRI can also help distinguish non-neoplastic conditions of the cervix such as cervicitis, nabothian cysts, polyps, cervical pregnancy and endometriosis.

Haematometra and haematotrachelos - accumulation of menstrual blood in a dilated, stenosed cervix - can be treated by cervical dilatation with temporary stenting, which was the case for Melanie. If obstruction is complete, reconstruction of the cervical canal can be performed, and successful pregnancy can follow.

- Dr Miller is a GP in west London

POSSIBLE CAUSES OF CERVICAL OBSTRUCTION
- Post-operative cone biopsy or other treatment to cervix.
- Cervical dysplasia and cancers.
- Hypo-oestrogenism/post- menopause.
- Post-op dilatation and curettage (D&C).
- Developmental anomalies.
- Cornelia De Lange syndrome (abnormal uterine contractile function).
- Endometritis.
- Fibroids.
- Adenomyosis.
- Endometrial hyperplasia.
- Uterine cancer.

LESSONS LEARNT FROM THIS CASE

- Cervical stenosis can present as a complication of treatment for cervical dyskariosis.

- Can be a late complication several years later.

- The presentation may be secondary amenorrhoea.

- Cervical stenosis is particularly likely in older women and in those who have had treatment in the postnatal period.

- Other complications of treatments to the cervix include bleeding, infection, pain and discharge.

REFERENCES

- El-Toukhy T A, Mahdevan S, Davies, A E. Cold Knife Cone Biopsy-a valid diagnostic tool and treatment option for lesions of the cervix. J Obst Gynaecol 2001; 21: 175-8.

- Dunn T S, Killoran K, Wolf D.Complications of outpatient LLETZ procedures. J Reprod Med 2004; 49: 76-8

- Brun J L, Youbi A, Hocke C. Complications, sequelae, and outcome of cervical conizations: evaluation of three surgical technics J Gynecol Obstet Biol Reprod 2002; 31(6): 558-64.

- Mossa M A et al. A comparative study of two methods of large loop excision of the transformation zone. BJOG 2005; 112(4): 490-4.

- Martin-Hirsch P L, Kitchener H.Interventions for preventing blood loss during the treatment of cervical intraepithelial neoplasia. Cochrane Database Syst Rev 2000;(2): CD001421.

- Lindeque B G. Management of cervical premalignant lesions. Best Pract Res Clin Obstet Gynaecol 2005; 19 (4): 545-61.

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