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Had a hysteroscopy and DandC done. Started bleeding heavily and pain in lower pelvis. Concerned

May 2013
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I had a hysteroscopy and D&C just over two weeks ago to remove a submucosal fibroid and at least one polyp, which were thought to be causing intermittent postmenopausal bleeding. However, last night I started bleeding so heavily that I soaked through the pad I was wearing and stained the furniture (not to mention my clothes). While that bleeding has subsided, that has been the pattern with my previous episodes as well (heavy bleeding at first, followed by spotting and then heavier bleeding finally ending after about 8 days). I also have a very intense localized pain in my lower right pelvis (which I didn't have before the surgery), and both the bleeding and pain get worse after a bowel movement (I've also noticed more constipation or problems with stools since the surgery). I am scheduled to have a post-operative appointment with the doctor who performed the surgery, but want to ask him the right questions, since he often makes me feel rushed. Because I am overseas now, I wouldn't be able to do more than have a quick talk to the doctor's nurse and I doubt it would do much good.

Please let me know your thoughts and any specific follow-up questions/concerns I should raise at my upcoming appointment.
Posted Sat, 27 Oct 2012 in Pregnancy
Answered by Dr. Sree Gouri SR 3 hours later
Thanks for the query.

The possible causes of your bleeding are:
Secondary hemorrhage from the site of hysteroscopic myomectomy.
It can occur due to dis-lodgement of blood clot from the wound site, infection etc.
Pain could be because of possible pelvic inflammatory disease after the procedure.
Before and during surgery the pattern of intake of fluids will alter and also intake of food that can lead constipation.
Better to use laxatives as straining for stools can disturb the wound and can lead to bleeding and pain.

One rare possibility is, if you had amenorrhea for less than 1 year that may not be true menopause and may be because of hormonal imbalance.
So when you undergone surgical procedure that stress and strain might have stimulated hypothalamo-pituitary-ovarian axis leading to bleeding.
Surgery can also lead to thyroid hormonal fluctuation which can also affect menstrual cycle.

So when you XXXXXXX your doctor discuss these possibilities with your doctor and take treatment accordingly.

Hope I have answered your query. I will be available to answer your follow up queries. If you are satisfied with all my answer, please rate the answer after closing the discussion.
Take care.
Above answer was peer-reviewed by
Follow-up: Had a hysteroscopy and DandC done. Started bleeding heavily and pain in lower pelvis. Concerned 5 hours later
Thank you, Doctor. Is there any possibility that the episode of very heavy bleeding could have been due to something other than the fibroid? I have had amenorrhea for more than 10 years, and was treated for about 4-5 months with an estrogen patch for osteoporosis only to have to stop a year ago when my blood calcium levels dropped significantly. The intermittent bleeding started both during and soon after stopping the estrogen but became more frequent in the last 3 months. Also, what is the treatment or recovery time of this intense pain is due to a surgical wound or pelvic inflammatory disease resulting from the surgery? The pain is almost unbearable and I also have difficult and frequent urination now along with the constipation (bladder pressure)? Will this go away on its own?
Answered by Dr. Sree Gouri SR 3 hours later

Your premature menopause could be because of hormonal imbalance. So when you supplemented estrogen that might have led to the development of fibroid, polyps and bleeding due to growth of uterine layers.
As I told previously if fibroid and its postoperative wound is not responsible for the bleeding the other possibility is hormonal fluctuation leading to endometrial thickness and bleeding.
As this is a rare possibility after 10 years of stopping the periods better to get histopathological examination of your fibroid, polyp, endometrium etc.
Your doctor might have done this and in the next visit you ask about this to rule out the possibility of endometrial carcinoma(Don't worry this is not common).
The healing of the surgical wound will usually complete by 2 weeks after procedure.
If the pain is due to pelvic inflammatory disease or take a course of antibiotics to treat these with your doctor's advice.
Meanwhile you can take analgesics to get relief from pain.
Once you get relieved of constipation by using laxatives you will have some symptomatic improvement.

Wish you Good Health, If you are satisfied with my response please rate the answer after closing the discussion.
Take care.
Above answer was peer-reviewed by
Follow-up: Had a hysteroscopy and DandC done. Started bleeding heavily and pain in lower pelvis. Concerned 54 minutes later
Dear Doctor,

Thanks for your input.

I did receive a pathology report indicating that the fibroid and polyp were benign, but merely stating that there was "proliferative endometrium" without characterizing this as normal/benign. Based on my limited understanding of proliferative endometrium, I am surprised that more than 1 year after stopping estrogen and a history of over a decade of amenorrhea (or premature menopause, as you state), I would have a thickened uterine lining. Could you clarify whether a reference to "proliferative endometrium" standing alone definitively means that the endometrium was normal or benign?

Also, since I had the surgery on 9/24, it has now been 16 days and the localized pain in my lower right pelvic region has remained pretty bad (before that, I had more generalized pain in the right side of the pelvis not unlike what I felt before the surgery and attributed to the fibroid), so is there a reason the surgical wound would not seem to be healing? I don't have a fever or any other signs of infection, but as mentioned, I do feel bladder pressure (even after the use of laxatives for constipation over the past several days), which causes me to urinate small amounts frequently and with some difficulty over the last several days. I usually don't experience this kind of thing with a thyroid levels and other hormonal levels checked out fine a couple of weeks ago, so isn't it unlikely that the levels have changed substantially since then?
Answered by Dr. Sree Gouri SR 1 hour later

The endometrium will be in proliferative phase under influence of estrogen.
As you are having just proliferative endometrium and not hyperplasia the possibilities are:
Some amount of estrogen will be produced in fatty tissues even after menopause.
If you have taken hormonal treatment to stop the bleeding before procedure.
Uterine prolapse can cause proliferative activity in endometrium in postmenopausal women.
Your other symptoms like pain in the pelvic region, bladder pressure, constipation etc can be seen in prolapse. And as fibroid can cause prolapse better to get examined once to rule out the possibility.

The stress of surgery can lead to fluctuation of hormonal levels even thoughf they were normal previously.
Wish you Good Health, If you are satisfied with my response please rate the answer after closing the discussion.
Take care.
Above answer was peer-reviewed by
Follow-up: Had a hysteroscopy and DandC done. Started bleeding heavily and pain in lower pelvis. Concerned 3 hours later
Thank you, Doctor.

Over the course of the day, I started to experience noticeable heaviness in my legs, to the point where I felt like I was dragging them just to get up some small steps. I think I had experienced something like this before, so it may be hormonal, but what is your best guess as to what levels may be contributing to this latest symptom and can you say if this is also at least consistent with the possibility of uterine prolapse?

I didn't take any hormonal treatment since I got off the estrogen patch a year ago, so that wouldn't explain the presence of estrogen. Is there any way to definitively diagnose uterine prolapse, and if I am determined to have it, what is the treatment? These symptoms really just started after the surgery (except for more generalized and less intense pain in my lower right abdomen, which I attributed to the fibroid), so is it possible that the surgery contributed to the condition (assuming I have it)?

I will get lab work done sometime next week and also raise the points you have made with my doctor during my post-op appointment, but if you could clarify this that would be great.

BTW, I assume from your answer that proliferative endometrium is necessarily normal or benign (again, the pathology report did not say anything about the endometrium tissue being benign, though it did say this about the fibroid and polyp that were removed). Is this assumption correct?

Thank you.
Follow-up: Had a hysteroscopy and DandC done. Started bleeding heavily and pain in lower pelvis. Concerned 1 hour later
I forgot to mention also that three years ago, I had a rectocele, sigmoidectomy and cystocele to address what was diagnosed as prolapsed organs. As a result of that surgery, I developed some disorder (the colorectal surgeon thinks a nerve must have been pressed perhaps during the surgery, done laparascopically) that has made it all but impossible for me to have bowel movements without use of digital assistance (except when the bowel movement is essentially like diarrhea or liquidy). I was tested a few weeks before having the hysteroscopy to see if I still had the prolapsed organs requiring a rectocele, sigmoidectomy and cystocele, but the ultimate diagnosis was that this was a pelvic floor disfunction. It has caused me to loose a lot of weight (I am down to my low 80 lbs from no normal weight 4-6 months ago of 94 or 95 lbs) because of stomach and bowel/colon pain, and the colorectal surgeon is now recommending that I get a stoma (colostomy) that, whle removable in theory, would be created as if it were going to be permanent (through a major surgical procedure). (First he recommends my receiving 5 days-worth of nutritional supplements through a pic-line (sp?), and I am also having an upper endoscopy this week just to rule out any possible ulcer contributing to the stomach pain.)

All of this is by way of background to see whether there is any chance that uterine prolapse (or any organs involving the bladder/uterus/vagina) might have been caused/exacerbated by the hysteroscopy procedure itself, since I was not experiencing anything like the symptoms I've described (except for the intermittent bleeding, constipation and some pain in the lower right pelvic area). I am also taking tramadol to deal with the stomach pain as well as bone pain that I've had over the last several years attributable to a rare version of a parathyroid disorder that removes calcium from the bones to put in the bloodstream.

Thank you for your anticipated insights.
Answered by Dr. Sree Gouri SR 15 hours later

Because of the prolapse pain in the back, heaviness in the legs can be noticed as prolapsed uterus will press on surroundings structures, with progression of the day the severity of symptoms will increase.
As such prolapse is not said to be a complication of hysteroscopy. But few cases reported.
Reference: WWW.WWWW.WW As you had previous history of cystocele, rectocele with weakness of pelvic floor and fibroid there is possibility for occurrence of prolapse after procedure.
By doing speculum examination and physical examination prolapse can be diagnosed.
Proliferative endometrium without hyperplasia is benign but not normal for you as you attained menopause 10 years back.
It could be because of increased estrogen levels in the body due to one of the causes I mentioned previously.
There is possibility that the procedure and position of hysteroscopy might have led to the returning of your bowel symptoms.
As you are having pelvic floor weakness, constipation after procedure leading to straining, fibroid which can drag the uterus down depending on its position in uterus there is possibility of uterine prolapse and may also be associated with anterior and posterior wall prolapse causing recurrence of cystocele, rectocele etc.
But don't worry I am telling all these as one possibility, so when you get examined with your doctor all these doubts will get clarified.

Wish you Good Health, If you are satisfied with my response please rate the answer after closing the discussion.
Take care.
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