Haematometra presenting as secondary amenorrhoea

Abstract

A 43-year-old woman presented with a 4-month history of amenorrhoea and a pelvic mass. Prior to this, her periods had been heavy and regular and she had not undergone any procedures to her uterus or cervix. An MRI scan revealed a well-defined mass lying within the central pelvis and the uterus and ovaries could not be identified separately. Examination under anaesthesia confirmed a haematometra with no underlying pathology. After this, the woman continued to have regular heavy periods.

Introduction

Haematometra occurs when there is an obstruction to menstrual blood flow. This can result either in primary amenorrhoea associated with a pelvic mass, or in secondary amenorrhoea, usually following a surgical procedure on the uterus or cervix. We report a case of a haematometra which occurred with no predisposing risk factors for its development and which presented with secondary amenorrhoea.

Case report

A 47-year-old nulliparous woman presented to her general practitioner with a 4-month history of amenorrhoea and a pelvic mass. Prior to this, her periods had been heavy and with a regular cycle. She had no past medical history of note. She underwent an ultrasound scan which revealed a pelvic mass of 11.8×10.2 cm, with septae, solid components and echogenic fluid within the mass. The left ovary was normal, but the right ovary could not be identified. As the origin of the mass was not clear, an MRI scan was performed which revealed a well-defined mass lying within the central pelvis, posterior to the bladder which was compressed and displaced anteriorly. The uterus and ovaries could not be identified, but the mass was in the region of the uterus; therefore, a diagnosis of possible haematometra was made.

The patient was admitted and underwent an examination under anaesthesia. This confirmed the finding of a 20-week mass arising from the pelvis. Speculum examination revealed no apparent cervix, but a pinhole was seen at the top of the vaginal vault, which moved with the uterus on bimanual examination. The pinhole was carefully dilated and 3 l of altered blood was released from the uterus. At the end of this procedure, the pelvic mass had resolved. A rigid hysteroscope was inserted, but the findings were suggestive of a false passage, so the procedure was abandoned.

The patient was reviewed in outpatients 8 weeks later. At that time she had had two periods since her operation. Both periods were heavy and lasted 5 days but were regular in cycle length. Transvaginal scan revealed a homogenous endometrium, which measured 5 mm in thickness.

Discussion

Cases of haematometra have been documented as causes of pelvic masses with primary amenorrhoea [1]. Cases of haematometra and secondary amenorrhoea are well documented and usually follow cervical surgery [2] or endometrial ablation [3]. Cases have also been reported where there is a uterine abnormality, but these cases usually present with pain and a pelvic mass, rather than with secondary amenorrhoea [4, 5]. Cases of haematometra have also been reported in postmenopausal women on HRT [6] or with an underlying endometrial malignancy [7].

Nowhere in the literature has a case of haematometra been reported as a cause of secondary amenorrhoea where there has been no cervical trauma and where the woman is menstruating regularly. The reason that this woman developed a haematometra while menstruating regularly is unknown.