Introduction
Cesarean section (CS) is one of the most common performed large surgical
intervention in, and its incidence has been increasing steadily,
accounting worldwide for one-third of all deliveries.1Only recently we became aware of long-term morbidity related to these CS
that may be related to a defect in the uterine CS scar, also called a
niche. It is defined as a disruption
of the integrity of the myometrium at the site of the
cesarean
scar with a minimum depth of 2 mm using
(sono)hysterography.2Other diagnostic methods include magnetic resonance imaging (MRI) or
hysteroscopy.3-5 Niches also called Cesarean scar
defects are reported in 49.6% ~ 64.5% in patients with
at least one previous CS, and it increases along with the number of CSs
up to 100% women with 3 or more CSs.6-8
Niches are associated with gynecological symptoms like postmenstrual
spotting, chronic pelvic pain, infertility and complications in
subsequent pregnancy. Postmenstrual bleeding is the most common symptom
that is reported in 29%-82% in women with a niche. It severely affects
women’s health and quality of life, in particular due to its unpredicted
nature.3, 9-11 In China, more and more women with a
diagnosed niche in the uterine scar ask for surgery or medical treatment
in order to treat postmenstrual spotting according to the clinical
experience.
So far, international acknowledged
guidelines on the preferred treatment for this indication are lacking.
Non-surgical and surgical methods have been reported for the treatment
of niche related bleeding symptoms.12, 13 Surgical
options include
laparoscopic,
transvaginal and
hysteroscopic
niche resections. In women with a relatively small niche with adequate
residual myometrial thickness (mostly>2.5mm), a
hysteroscopic niche resection is the least invasive
approach.14-16 A hysteroscopic niche resection reduces
postmenstrual spotting with an average of 4 days.12,
17 Non-surgical methods include continuous or cyclic hormonal therapies
and Levenorgestrel-releasing intrauterine device
(LNG-IUD).12 Although the number of studies evaluating
the effect of these medical treatments in the reduction of postmenstrual
spotting is very limited. Concerning LNG-IUD only one study, including 6
patients only, indicated a positive effect.18As far as we are aware of
comparative studies between
hysteroscopic niche resection and LNG-IUD in the treatment of
postmenstrual spotting
lacking.
Therefore, we conducted a
prospective cohort study to compare the effect of a hysteroscopic niche
resection and LNG-IUD on niche related postmenstrual spotting.