PII: S0015-0282(07)01461-6

Abstract

Reply of the Authors: We thank Dr. Oronzo Ceci and his colleagues for their interest and insightful comments regarding our article (1Tahara M. Shimizu T. Shimoura H. Preliminary report of treatment with oral contraceptive pills for intermenstrual vaginal bleeding secondary to a cesarean section scar.Fertil Steril. 2006; 86: 477-479Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar). The intent of our study was to evaluate the effectiveness of hormone therapy in patients with recurring vaginal bleeding after cesarean section. In his letter, Dr. Ceci pointed out that the prevalence of intermenstrual uterine bleeding (IUB) with caesarean scar pouch in our study was low compared with other studies (2Morris H. Surgical pathology of the lower uterine segment caesarean section scar: is the scar a source of clinical symptoms?.Int J Gynecol Pathol. 1995; 14: 16-20Crossref PubMed Scopus (146) Google Scholar, 3Fabres C. Arriagada P. Fernández C. Mackenna A. Zegers F. Fernández E. Surgical treatment and follow-up of women with intermenstrual bleeding due to cesarean section scar defect.J Minim Invasive Gynecol. 2005; 12: 25-28Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar). As reported previously, uterine scar dehiscence is diagnosed in approximately 0.3% to 1.90 % of women who have undergone cesarean section (4Bromley B. Pitcher B.L. Klapholz H. Lichter E. Benacerraf B.R. Sonographic appearance of uterine scar dehiscence.Int J Gynaecol Obstet. 1995; 51: S3-S6Abstract Full Text PDF PubMed Scopus (26) Google Scholar). We examined 157 patients who complained of abnormal bleeding after having had a cesarean section, and 11 women demonstrated a defect at the expected site of the postsurgery uterine scar, which indicates that the cause of IUB in women who have had caesarean sections is not always attributable to uterine scar dehiscence. As Dr. Ceci stated in his letter, it is not clear why the problem occurs, and its actual incidence is still unknown (5Ceci O, Scioscia M, Vicino M, Pinto L, Pontrelli G, Costantino A, Bettocchi S. Clinical evaluation of cesarean scar pouch detected by hysteroscopy. World Congress of Minimally Invasive Gynecologic Surgery; June 21–24, 2006; Dubrovnik, Croatia; presentation 79–2006.Google Scholar). For the patients with IUB but without defects at low segment caesarean section, we usually administered treatment for dysfunctional uterine bleeding. Dr. Ceci also asked how many of those women experienced abnormal bleeding in the ensuing months. Although we have no information about two patients who did not return for consultation, the other patients were free of abnormal vaginal bleeding after cessation of the hormone therapy for three to six cycles and have remained asymptomatic up to now. Although our data show that hormone therapy seems beneficial in preventing recurrent vaginal bleeding at least in the short term, its long-term efficacy still must be evaluated. We performed saline sonohysterography after transvaginal sonography of the pelvis. Regarding the use of sonohysterography, our impression is that vaginal ultrasound alone may occasionally miss such defects. In three of our 11 cases, the defects were very subtle by transvaginal sonography alone but were obvious via sonohysterography. As sonohysterography is safe, well tolerated, and feasible in an outpatient setting, we believe that saline sonohysterography should be considered a reliable outpatient procedure in the management of patients with IUB. In our opinion, office hysteroscopy may not be acceptable to all patients because such an examination requires requesting time off work and is more expensive and invasive than sonohysterography; however, this has to be balanced against the clinical benefits and the burden to the patients. An office hysteroscopic procedure that allows us to coagulate endometrial vessels with the bipolar electrode is admittedly useful. However, our data suggest that hormone therapy can be the primary option for abnormal uterine bleeding after cesarean deliveries. We believe that the surgical management of abnormal bleeding should be reserved for situations in which medical therapy has been unsuccessful or is contraindicated. We read the letter with great interest regarding the association between the development of symptoms and the timing of caesarean section. We look forward to further analysis of their data when it is published, and, once again, we thank Dr. Ceci for the additional opportunity to discuss our study. Recurrent intermenstrual bleeding secondary to cesarean section scars?Fertility and SterilityVol. 88Issue 3PreviewTo the Editor: Full-Text PDF