When you see this title, you may smile: Scrape deep! Scrape hard!
Dr. Li is going to speak on this topic again today.
When menstruation is scarce, scanty or amenorrheic, and there is cyclic lower abdominal pain after abortion, we call it “post-abortion uterine adhesions”. The reason is repeated scraping during the operation. The scraping is so deep that the endometrial basal layer is damaged, resulting in endometrial adhesions or cervical canal adhesions. Note that the most important key word in this paragraph is “endometrium basal layer”. When it is injured, menstruation becomes abnormal.
Next, we have to talk about menstruation. “What role does the endometrial basal layer play in causing abnormal menstruation?
First, let’s understand the formation of menstruation: menstruation is the cyclical shedding of the endometrium that accompanies the cyclical changes of the ovaries. Note that the key words are cyclical, ovaries, and endometrium. In other words, menstruation must have a cyclic quality and be associated with the ovaries, the endometrium.
The ovaries have the function of producing eggs and ovulating and secreting female hormones; the endometrium is divided into a functional layer and a basal layer. The functional layer is the site of embryo implantation and is regulated by the ovaries, with cyclic proliferation, secretion and shedding changes; the basal layer regenerates after menstruation and repairs the endometrial trauma, re-forming the functional endometrial layer. Let’s draw an analogy: if menstruation is a small plant, the functional endometrial layer represents the part of the plant that spreads out on the ground; the basal endometrial layer represents the part of the plant that is underground such as the roots. Once the endometrium is scraped to the basal layer, the “root” is injured, will the grass (menstruation) still grow well?
How can I know that the abortion is “scraping too deep! Scraping too hard!”? How can I tell if I have scraped too deeply? When you have a low menstrual flow or your period does not come on time after the procedure, we need to do an ultrasound to find out the thickness of the endometrium after ruling out pregnancy.
The normal endometrium is regular in the menstrual cycle. The menstrual period (1st-4th day of menstruation) we already know is the exfoliative bleeding of the functional endometrial layer from the basal layer and ultrasound is generally not recommended. This is the period when the primordial follicles (the only form of oocyte reserve, of which there are about 300,000 in a woman’s lifetime) in the ovary begin to evolve into sinus follicles, a process influenced by the release of follicle stimulating hormone (FSH) and estrogen from the pituitary gland, which is the reason why the ovarian reserve needs to be seen on days 2-3 of menstruation for infertility.
On days 5-14 after menstruation, when the endometrium can grow from 0.5mm to 3-5mm; during this period, around day 7 of the menstrual cycle, the ovary has recruited a group of sinus follicles (3-11) under the synergistic effect of estrogen and FSH, but only one follicle gets favored to become the dominant follicle. On days 11-13 of the menstrual cycle, the dominant follicle enlarges to 18 mm and secretes the most estrogen, with concentrations up to 300 pg/ml; the increased estrogen level in turn stimulates the pituitary gland to release luteinizing hormone (LH), and the large amount of LH release causes the mature egg to be expelled from the follicle, which is ovulation (only 400-500 follicles develop and ovulate in a woman’s lifetime.) . Ovulation mostly occurs about 14 days before the next menstrual period. After ovulation, the endometrium continues to proliferate and the endometrial glands secrete, which is rich in nutrients that facilitate the implantation of the fertilized egg in the endometrium.
During this period, the follicles in the ovaries discharge their eggs, the follicular fluid flows out, the walls of the follicular cavity collapse and the corpus luteum slowly forms. The corpus luteum mainly secretes progesterone (P) and also estradiol (E2). The volume of the corpus luteum (prone to luteal rupture!) and its function reach their peak on the 7-8th day after ovulation (i.e. day 22 of the menstrual cycle) If the ovum is fertilized, the corpus luteum is affected by chorionic gonadotropin (HCG) to maintain pregnancy until it degenerates at the end of the third trimester; if the ovum is not fertilized, the corpus luteum begins to degenerate. The luteal function is limited to 14 days. If the egg is not fertilized, the corpus luteum begins to degenerate and its function is limited to 14 days.
What a complicated menstruation! Do you understand? Dr. Li concludes that the thickness of the endometrium can reflect the three functions of the menstrual cycle to some extent (not completely): ovarian function, follicular function, and luteal function. If the ultrasound indicates a thin endometrium (less than 5mm), attention should be paid to ovarian function: clinically, the six sex hormones mainly look at FSH, LH and E2; if the endometrium is thick (more than 6-7mm), the ultrasound can monitor the follicles: the presence of dominant follicles (increasing to 18mm in diameter), combined with the six sex hormones, the concentration of estrogen (E2) can reach 200-300pg/ml, suggesting follicular function Normal; progesterone (P) reaching 3ng/ml can be considered as a sign of ovulation; progesterone (P) needs to be greater than 10ng/ml at mid-luteal phase; when progesterone (P) is greater than 15ng/ml and estrogen concentration (E2) reaches 150-250pg/ml is considered normal luteal function.
When menorrhagia, scanty menstruation or amenorrhea occurs after abortion, the examination we have to do is gynecological examination + ultrasound + serum sex hormone six check. To diagnose “post-abortion cavity adhesions”: history of abortion + scanty or amenorrhea + vaginal ultrasound (in severe cases, the endometrium is missing and discontinuous) + normal serum sex hormone measurement. Hysteroscopy is the gold standard for the diagnosis of uterine adhesions.
About treatment: The most common method for “post-abortion uterine adhesions” is hysteroscopic separation of uterine adhesions, followed by hormonal therapy to promote endometrial repair. If the diagnosis of “post-abortion cavity adhesions” is not yet reached, the main treatment is to establish artificial menstrual cycles, promote ovulation (commonly used drugs such as progesterone, clomid, clomiphene, etc.) or Chinese herbal medicine to promote endometrial repair.
Finally, Dr. Li would like to appeal to: cherish the opportunity to have children, no reproductive requirements must do a good job of contraception (in vitro ejaculation, safe period contraception, emergency contraception are not reliable), after the abortion before the menstrual flow, it is best not to have sex. The first is the poor resistance of women after surgery, easy infection, there will be lower abdominal pain (Dr. Li encountered such a patient, the same night after the abortion had intercourse, the result in the middle of the night in severe pain in the lower abdomen, crying and hanging emergency room to see the doctor); the second is in case of accidental pregnancy (many patients in the post-operative half a month may be ovarian recovery function), of course, menstruation will not come. If you are more demanding and receptive, you can take oral compound short-acting contraceptive pills after surgery, which serve to promote the growth and recovery of the endometrium, reduce post-operative bleeding, increase the consistency of cervical mucus, prevent bacterial invasion, prevent pelvic infection and prevent uterine adhesions.
This article is authorized by Dr. Haiyan Li.