Cervical Stenosis Angela Keating MD Basics Description Stricture of the cervical os; can be complete or incomplete Age-Related Factors

s More fre uent in postmenopausal !omen "pidemiolog# Most common in h#poestrogenic !omen and !omen !ho have had a cervical procedure$ Ris% Factors Congenital Ac uired&
o

'perative&

Cervical coni(ation Cervical cauteri(ation )""* Cr#otherap#

o o o o o

Radiation +nfection ,eoplasia -#poestrogenic state .rauma

*athoph#siolog# Diameter of normal cervi/ at the e/ternal os is 0123 mm in nulliparous !omen and 43 mm in most !omen !ho have had a vaginal deliver#$ Diameter of the congenital stenotic cervical os is decreased due to lac% of canali(ation or inade uate canali(ation$

Diameter of the ac uired stenotic cervical canal is decreased due to adherence of ra! surface !ithin the cervical canal or contraction from scarring$ +f cervical os diameter is 56 mm7 often increased fluid is present !ithin the uterine cavit# !ith retrograde menstruation$

Associated Conditions +nfertilit# D#smenorrhea

"ndometriosis

Diagnosis Signs and S#mptoms -istor# S#mptoms depend on !hether partial or complete stenosis is present and !hether patient is premenopausal or postmenopausal$ 8st sign ma# be inabilit# to complete a procedure due to inabilit# to pass the instrument through the cervical canal into the uterus 9endocervical curettage7 endometrial biops#7 h#steroscop#7 insemination: Revie! of S#stems *remenopausal& o D#smenorrhea7 pelvic pain
o

Abnormal uterine bleeding 9amenorrhea7 oligomenorrhea7 prolonged menses: -ematometra7 p#ometra "ndometriosis +nfertilit# )ac% of cervical dilation in labor

o o o o

*ostmenopausal&
o o

As#mptomatic -ematometra7 h#drometra7 p#ometra

*h#sical "/am +nabilit# to pass 826 mm dilator through cervical canal into uterine cavit# "nlarged uterus7 tender uterus .ests +maging *elvic ;S to assess for fluid !ithin uterine cavit# Differential Diagnosis .rauma Asherman<s s#ndrome 9see topic: 'ther=Miscellaneous M>llerian anomal# .reatment ?eneral Measures Dilate the cervi/ to allo! access to and drainage from the uterine cavit#; ma# be done under ;S guidance& Dilator7 lacrimal duct probe7 os finder )aminaria Medication 9Drugs: Misoprostol for dilation 96@@ Ag *' or vaginall# for off-label use: Consider menstrual suppression if recurrent hematometra

Surger# -#steroscopic canali(ation Carbon dio/ide laser vapori(ation

)""*

Follo!up Disposition +ssues for Referral *#ometra ma# be associated !ith uterine malignanc#7 and thus !ould prompt referral to a g#necologic oncologist$ Congenital stenosis or M>llerian anomalies ma# be discovered in adolescence and should prompt referral to clinician e/perienced in their management$ *rognosis 'ften recurrent if related to h#poestrogenic state or if scar tissue is not removed *atient Monitoring *ossible single intervention *ossible serial dilations

Consider estrogen therap# post-treatment

*$31 Bibliograph# Baggish MS7 et al$ Carbon dio/ide laser treatment of cervical stenosis$ Fertil Steril$ 8B3C;D398:&6D263$ Dar!ish A7 et al$ Cervical priming prior to operative h#steroscop#& A randomi(ed comparison of laminaria versus misoprostol$ -uman Reprod$ 6@@D;8B98@:&6EB82 6EBD$ Krant( K"$ .he anatom# of the human cervi/7 gross and histologic$ +n& Moghissi K7 ed$ .he Biolog# of the Cervi/$ Chicago& ;niversit# of Chicago *ress; 8BCE;82E@$ ,o#es ,$ -#steroscopic cervical canal shaving& A ne! therap# for cervical stenosis before embr#o transfer in patient undergoing in vitro fertili(ation$ Fertil Steril$ 8BBB;C891:&BF12BFF$ *abuccu R7 et al$ Successful treatment of cervical stenosis !ith h#steroscopic canali(ation before embr#o transfer in patients undergoing +GF& A case series$ H Minim +nvasive ?#necol$ 6@@1;8691:&DEF2DE3$ Miscellaneous Abbreviations )""*I)oop electrosurgical e/cision procedure Codes +CDB-CM J F66$D Cervical stenosis J F63$D +nfertilit# associated !ith congenital structural anomal# J F1D$F Cervical stenosis in pregnanc#7 labor7 and deliver# J FF@$6 Cervical stenosis causing obstructed labor J C16$DB Congenital stenosis of cervical canal *atient .eaching

Discuss follo!-up compliance to maintain open cervical canal