A Comparison of Hysterectomies for Bleeding With Hysterectomies for Pain

Abstract

Objectives. We recently suggested that increased intramural pressure may often explain pain and/or bleeding. Hysterectomies for bleeding tend to have outward bulges and endometrial vascular ectasia, while hysterectomies for pain tend to have deflection of pressure inward by subserosal ridges, which promote inner myometrial elastosis (IME). Study design. We analyzed causes of increased intramural pressure in 58 hysterectomies for pain and/or bleeding, excluding clinically fibroid uteri and prolapsed uteri. Postfixation photographs were used to avoid missing grossly obvious myometrial hyperplasia (MMH). Results. The most common cause of increased intramural pressure was grossly obvious MMH in 40/58 cases (69%). Other causes included clinically occult myomas (3 cases), adenomyosis (6 cases), and multifactorial causes (7 cases). Hysterectomies for bleeding weighed more than hysterectomies for pain ( P = .035). Hysterectomies for pain had more IME than hysterectomies for bleeding ( P = .029). Conclusions. When subserosal ridges deflect pressure inward, bulky MMH may cause pelvic pain and IME, but when they do not, bulkier MMH in heavier uteri may lead to both outward bulges and abnormal bleeding from endometrial vascular ectasia.

Relationship between magnetic resonance imaging‐based classification of adenomyosis and disease severity

“…There have been several reports that diffuse adenomyosis is associated with heavy menstrual bleeding 30–34 . More recently, pathological examination of the removed uterus revealed that hysterectomies for bleeding have outward bulges, while hysterectomies for pain have inward bulges by subserosal ridges; and that hysterectomies for bleeding were heavier than hysterectomies for pain 35 . Thus, heavy menstrual bleeding may be positively associated with the depth of endometrial invagination into the myometrium 30 .…”

Abnormal Uterine Involution May Lead to Atony and Postpartum Hemorrhage: A Hypothesis, With Review of the Evidence

“…Our experience confirms the observation of Shahid et al (Figure 1(b)); however, our studies of developing uteri and nonpregnant hysterectomies for bleeding suggest that this outer wall edema and vascular ectasia (outer pressure effects) is secondary to increased intramural pressure, as first suggested by Farrer-Brown and co-workers in the 1970s. 5,10,16,18,20,27 We believe this pressure-induced outer wall edema has nothing to do with myometrial involution. However, increased intramural pressure in the growing myometrium of early pregnancy—associated with the palpable bump in the abdomen that is a sign of early pregnancy—may lead to venous obstruction, with endometrial vascular ectasia, fibrin thrombi, and stromal breakdown, causing early pregnancy bleeding.…”

“…The theory of metropathy, still neither proven nor disproven, persists to the present era. 5,16,18,20 It is ironic that in the 19th century, knowledge of uterine atony led to the hypothesis that myometrial histopathology (metropathy) could cause serious abnormal bleeding, and that we now suggest the pathophysiology of myometrial involution may lead to uterine atony.…”

“…This has been seen previously in nonpregnant uteri, and is interpreted as minor tissue damage secondary to increased intramural pressure. 5,13,16 (C) (400×)—Elastic van Gieson stain of postpartum hysterectomy shows numerous apoptotic globules (arrows), consistent with single cell death of myocytes.…”

“…However, increased intramural pressure in the growing myometrium of early pregnancy—associated with the palpable bump in the abdomen that is a sign of early pregnancy—may lead to venous obstruction, with endometrial vascular ectasia, fibrin thrombi, and stromal breakdown, causing early pregnancy bleeding. 16,18,28…”