Office hysteroscopic treatment of vaginal bleeding and related pain after supracervical hysterectomy: A case report

Abstract

Vaginal bleeding and pelvic pain are frequently observed after supracervical hysterectomy with preservation of the ovary. In this article, we describe original and successful office hysteroscopic partial epithelial ablation of the cervical stump with a bipolar instrument, in a patient suffering from vaginal bleeding and pain, occurred after supracervical hysterectomy. Hysteroscopy was performed on a 48-year-old Caucasian patient, which was brought to our attention for vaginal bleeding and associated pain 1 year after supracervical hysterectomy. The procedure was carried out in an office setting using the vaginoscopic approach, using the 4-mm continuous-flow operative office hysteroscope with a 2.9-mm rod lens. After introducing the hysteroscope into the cervical canal, a recess with hyperplastic residual epithelial tissue was usually found. We performed partial epithelial ablation with bipolar Versapoint Twizzle Electrode to minimize vaginal bleeding and pain by reducing hormone-responsive tissue. At 4 years of follow-up, the patient reported complete disappearance of pain and only few and irregular vaginal bleeding. Office hysteroscopic treatment of vaginal bleeding and associated pain after supracervical hysterectomy is a simple procedure that can be easily introduced into common clinical practice.

Introduction

In recent decades, technological improvements and the expertise of specific operators have allowed office operative hysteroscopy to treat an increasing number of pathological gynecological conditions, traditionally treated in an operative setting. ¹

The international literature reports office hysteroscopic procedures for both usual and unusual conditions such as hysteroscopic sterilization, office metroplasty, hematometra, diagnosis and treatment of vaginal lesions, treatment of cystic uterine neoformations, diagnosis and treatment of endocervical ossification, removal of uterovaginal packing, and bleeding from the cervical stump. ¹

Supracervical hysterectomy (SH), either laparoscopic (LSH) or abdominal, is a surgical option for women with benign conditions requiring hysterectomy without a history of cervical dysplasia. ² During the 1990s, LSH, with or without concurrent endocervix excision or coagulation, ³ became the preferred laparoscopic procedure; however, with improvements in surgical skills, total laparoscopic or laparoscopic-assisted vaginal hysterectomy almost replaced the supracervical approach.

Many observations reported vaginal bleeding and pelvic pain frequently associated with patients after SH.^4,5 However, there are no recommendations on how to treat these conditions. ⁶

The present manuscript describes the original and successful office hysteroscopic treatment of vaginal bleeding and pain, which occurred after SH.

Case presentation

A 48-year-old Caucasian woman came to our attention for cyclic vaginal bleeding and pelvic pain, occurred 1 year after SH with ovarian preservation, performed for benign indication. The patient had a BMI of 24.6 kg/m², she had no significant comorbidities, no chronic illnesses, and took no hormonal therapy nor regular medications. Symptoms were described as moderate, with monthly recurrence. Information regarding the prior SH was obtained from the patient’s electronic hospital record and operative report archived in our facility’s computerized documentation system. Histopathological report from the prior hysterectomy confirmed benign leiomyomas and proliferative endometrium without atypia.

Differential diagnoses included cervical cancer, cervical stump endometriosis, and granulation tissue. Cervical cytology and human papilloma virus (HPV) testing were performed and yielded negative results, excluding cervical neoplasia. Laboratory investigations were within normal limits, including complete blood count (Hb 13.4 g/dL, WBC 6.700/mm³) and hormonal profile (FSH 8.4 mIU/mL, LH 6.9 mIU/mL, estradiol 87 pg/mL, progesterone 0.8 ng/mL), confirming a premenopausal status. Transvaginal ultrasound demonstrated a normal cervical stump and adnexa, with no pelvic fluid.

Consequently, office hysteroscopy was performed to directly visualize the cervical canal and identify possible residual epithelial tissue or epithelial proliferation responsible for the bleeding, enabling simultaneous diagnosis and treatment. The patient underwent office hysteroscopy at the Department of Maternal and Child Health, Operative Unit of Obstetrics and Gynecology, AORN. S.G. Moscati, Avellino, Italy.

Hysteroscopy was performed in an office setting using the vaginoscopic approach without speculum or tenaculum, without analgesia or anesthesia. The procedure was performed using a 4-mm continuous flow operative office hysteroscope with a 2.9-mm rod lens (Bettocchi office hysteroscope size 4; Karl Storz, Tuttlingen, Germany). Normal saline solution was used as distension medium, and the pressure was automatically controlled by an electronic irrigation and suction device (Endomat; Karl Storz). The pressure was initially set at 45 mm Hg, this being the balance of irrigation flow ~200 mL/min and a vacuum of 0.2 bars. Then it was increased to improve endoscopic view. After the introduction of the hysteroscope in an almost normal cervical canal, a recess with hyperplastic residual epithelial tissue was found (Figure 1(a)). This finding was interpreted as hormonally responsive tissue; therefore, a biopsy sample was taken from the residual epithelial area before ablation to exclude atypia or malignancy. Then, partial epithelial ablation with bipolar Versapoint Twizzle Electrode (Gynecare, Somerville, NJ, USA) of the recess and cervical epithelium (Figure 1(b)), to eliminate the bleeding source, minimizing vaginal bleeding and pain.

Figure 1.

(a) Fundus of cervical channel with hyperplastic residual epithelial tissue. (b) The bipolar Versapoint Twizzle Electrode (Gynecare, Somerville, NJ, USA) used to perform partial epithelial ablation. (c) Markedly reduced epithelial tissue at term of the procedure.

The bipolar Versapoint Twizzle Electrode (Gynecare) was set in VC3 vapor cutting mode with a desiccation power of 50 W. The procedure was carried out cauterizing the residual epithelial tissue (Supplemental Material).

The total duration of the technique was 5 min, and at the end of the procedure, the epithelium was markedly reduced (Figure 1(c)). The woman experienced low pain (with visual analog score-3). Pathological examination of the cervical biopsy showed micro glandular hyperplasia and no residual endometrial foci.

Follow-up included outpatient visits at 3-, 6-, and 12-month post-procedure, and annually thereafter. Pelvic ultrasound and clinical evaluation confirmed symptom resolution and absence of recurrence at 4 years.

Discussion

After SH, vaginal bleeding is reported with an incidence of 0%–37%, in a median time of 4 years after the surgical procedure.^7,8 Variables that can contribute to this wide range include the surgical approach to cervical amputation, the definition of intermittent vaginal bleeding, and the duration of follow-up.^6,9 When present, the volume of cyclical bleeding is reported to be small,^4,8 with minimal clinical effect.

Consequently, international guidelines state that all women undergoing SH should be warned of the possibility of continuous intermittent vaginal bleeding and the need for cervical surveillance. ⁶ No available method prevents or predicts ongoing intermittent vaginal bleeding after SH. ⁶

Pelvic pain after SH or total hysterectomy is described and different causes are reported. ⁶ The international literature lacks data on the treatment of pain and bleeding after SH. Therefore, the literature that evaluates SH is limited and only three randomized controlled trials, including 342 women, have reported psychological results, complications, and additional cervical procedures.^4,10,11

Furthermore, some authors in the surgical procedure statement have reported cervical treatment after removal of the uterine body: residual endometrium through endocervical biopsy of the cervical stump, or intraoperative treatments of the cervical canal through reverse conization or electrosurgical destruction. ⁶

Operative or office hysteroscopic procedures to treat vaginal bleeding have recently been reported. ¹ However, there are no recommendations in the international literature on how to treat these conditions.

This article describes the successful office hysteroscopic treatment of vaginal bleeding and associated pain after SH.

The procedure performed was simple and only required a few technical tricks. The pressure was increased by closing the suction and increasing the flow and pressure of the irrigation to 250 mL/min and 150 mm Hg, respectively, with only minimal discomfort for the patient.^12,13 This was due to the fact that the cervical nerves are partially transected during SH and, additionally, no sensitive nerve terminals have been demonstrated in the endometrial layer, unlike in the myometrium, which has branching medullary fibers. ¹⁴

Furthermore, the set of the bipolar Versapoint Twizzle Electrode (Gynecare) in the mildest vapor cutting mode (VC3) and the halving of the power setting to 50 W, together with pulsed activation of the bipolar circuit, carried the advantage of producing minimal dissection of the tissue with minimal bubble generation and high patient tolerance. In our procedure, we preferred the use of the Twizzle electrode because it can work closer to the stromal cervical layer, with a lower power setting and, consequently, with less patient discomfort. Indeed, we did not need to use any kind of anesthesia.

Otherwise, Pontrelli et al. treated the residual endometrial tissue of the cervical stump using a Spring electrode (Gynecare), performing an office hysteroscopy with the use of conscious sedation. ¹

Therefore, the use of the bipolar Versapoint Twizzle Electrode (Gynecare) enabled “office” treatment of present bleeding without anesthesia or analgesia, by electro cauterization of cervical epithelial tissue. The procedure described was safe and effective for the patient, who considered her quality of life satisfactory at 1 year of follow-up.

Office hysteroscopic treatment of vaginal bleeding and associated pain may represent a first-line procedure.^1,12,13 After an eventual failure of the hysteroscopic procedure, a laparoscopy could be advised to remove possible adhesions, which cause pain, and a trachelectomy was proposed to the patient.

Conclusions

Office hysteroscopic partial epithelial ablation of the cervical stump using bipolar energy is a safe, minimally invasive, and effective treatment for post-SH vaginal bleeding and pain. The procedure can be performed in an outpatient setting with excellent tolerance.

Supplemental Material

sj-pdf-1-sco-10.1177_2050313X251407045 – Supplemental material for Office hysteroscopic treatment of vaginal bleeding and related pain after supracervical hysterectomy: A case report

Supplemental material, sj-pdf-1-sco-10.1177_2050313X251407045 for Office hysteroscopic treatment of vaginal bleeding and related pain after supracervical hysterectomy: A case report by Maria Antonietta Castaldi and Salvatore Giovanni Castaldi in SAGE Open Medical Case Reports