Isthmocele: causes, symptoms and treatments

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Catherine Le Nevez
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An unusual bleeding between one menstruation and the next: if this event occurs and continues over time after one or more deliveries occurred with a caesarean section, the cause could be an isthmocele, an alteration of the endometrium, the inner lining of the uterus, just following the caesarean section.

In addition to the discomfort of leaks and any pain, this condition could lead to infertility and complications in the event of future pregnancies. Fortunately, however, it can be solved either by pharmacological means, with the pill, or with a hysteroscopy, a small surgery performed directly from inside the uterine cavity. We talk about it with the gynecologist Massimo Origoni, professor of the Vita Salute University at the San Raffaele Hospital in our city.

Istmocele, what is it about?

Histmocele is a condition that typically occurs after a cesarean section or several repeated cesareans. In some cases, this leads to a loss of the lining tissue from the inside of the uterus, the endometrium, right where the surgical cut was made. In turn, the loss of endometrial tissue leads to the formation of a kind of sac in which menstrual blood tends to stagnate.

At the moment it cannot be excluded that other interventions, such as scrapings or interventions for the removal of fibroids, can also lead to the formation of an isthmocele. However, these possible correlations need to be better investigated.

How common is isthmocele?

It is estimated to occur in 25-30% of women - about one in four - who have undergone one or more caesarean sections. However, it must be said that often isthmocele is completely asymptomatic and therefore the woman does not even notice the problem, or the condition emerges occasionally, during an ultrasound performed for other reasons.

What are the symptoms of isthmocele?

In many cases, isthmocele does not lead to particular manifestations and symptoms.

In symptomatic cases, the main manifestations are irregularities in the menstrual cycle and in particular abnormal bleeding that continues even after menstruation. These are more or less intense discharge - intermenstrual spotting - which can last for a few days or until the next menstruation. The losses are due to the fact that menstrual blood collects in a sort of sac that forms due to the loss of endometrial tissue, and is released gradually.

Some women also experience more severe menstrual pain, or chronic pelvic pain: similar to that of a menstruation, but which lasts indefinitely. It is not certain that these symptoms manifest themselves from the first menstruation after the caesarean section: they can also appear after a very variable time.

How is the diagnosis made?

A simple transvaginal ultrasound is enough for the diagnosis, sometimes with the help of a fluid that stretches the uterine cavity. As always in these cases, the greater the experience of the operator and the center where the ultrasound is performed, the better.

Could there be consequences for fertility or subsequent pregnancies?

There are still no definitive data on the relationship between isthmocele and infertility, but it is actually possible that the presence of this alteration of the endometrium has negative consequences on the possibility of becoming pregnant again. Certainly, if a woman who has already given birth with one or more caesarean sections is unable to have a new pregnancy, this aspect is also worth investigating.

On the other hand, we know with more certainty that the presence of isthmocele increases the risk of complications during any subsequent pregnancies. These complications depend on the fact that the placenta tends to nestle exactly where the endometrial tissue is missing, which can hinder its proper development. All this increases the risk of spontaneous abortion - because the placenta cannot support the growth of the embryo well - or of detachment of the placenta itself.

These risks are higher in cases where istmocele is symptomatic. If there are no symptoms, it means that the alteration of the endometrium is likely to be minimal and likely to have no consequences.

How is it done?

In asymptomatic cases nothing is typically done. In the symptomatic ones, the first step is usually a drug therapy, with the estrogen-progestogen pill. By regulating the menstrual flow, this combination of hormones helps to restore the endometrium to normal conditions, solving the problem.

If after six months of treatment no results are seen, a surgical correction becomes indicated, which is carried out by hysteroscopy. It is a minimally invasive endoscopic technique, which allows to intervene directly in the uterus cavity through the insertion of a small instrument via the vagina. Hysteroscopy allows you to remove the "edges" of the sac in which menstrual blood stagnates, aligning them with the surrounding tissue.

The surgery is performed under sedation, a very mild form of anesthesia, is short-lived - you usually only stay in the hospital for one day, from morning to night - and is generally well tolerated.

Does the surgery involve special risks?

Like any surgery, it is not entirely risk-free. The main ones - bleeding or perforation of the uterus - can still be well controlled during the surgery itself. The advice is obviously to contact experienced centers and operators.

Hysteroscopic correction of isthmocele allows you to search for a new pregnancy with confidence. And, if this occurs, it does not preclude the possibility of a vaginal birth. Obviously if the woman shows the desire to try to give birth naturally after a previous caesarean section.

  • ismocele
  • Caesarean section
  • Caesarean section
  • infertility
  • placenta
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