Cervical Stenosis

Cervical stenosis is narrowing or closure of the cervical canal, which blocks the flow of menstrual blood, secretions and sperm.

• Causes include cervical surgery (cone biopsy, LEEP, cryotherapy), radiotherapy, menopausal atrophy, infection, tumour, endometrial ablation and congenital anomalies.
• Blocked secretions form haematometra or pyometra.
• Treatment is by dilatation and prevention of reclosure.

Amenorrhoea or scanty periods, cyclical pelvic pain, dysmenorrhoea, infertility, difficult or failed intrauterine device insertion, and a difficult cervical smear.

• Pinpoint external os; enlarged tender uterus if haematometra or pyometra is present; fever and purulent discharge with pyometra.
• Differential diagnosis: Asherman syndrome, cervical cancer, hypothalamic amenorrhoea, pregnancy, endometrial cancer, pelvic inflammatory disease.
• Complications: haematometra, pyometra, retrograde menstruation and endometriosis, infertility, perforation during dilatation.

Diagnosis is by examination and ultrasound, with exclusion of pregnancy and malignancy.

• Pregnancy test; speculum examination; sounding the canal gently.
• Transvaginal ultrasound showing fluid or blood in the endometrial cavity.
• Hysteroscopy or MRI where available; biopsy of any suspicious tissue.
• Full blood count and blood cultures if fever is present.
• Endometrial sampling in postmenopausal women.

Dilate the canal safely, drain any collection, and prevent reclosure.

• Supportive: analgesia, hydration, and counselling on cyclical symptoms; avoid forced dilatation without guidance.
• Pharmacological: before dilatation, exclude pregnancy, then misoprostol 400 micrograms vaginal 3 hours before the procedure in premenopausal women. In postmenopausal women use oestriol 0.1 percent cream 0.5 g intravaginal nightly for 2 weeks before. Analgesia with ibuprofen 400 mg oral 8-hourly with food (maximum 1.2 g in 24 hours) and paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours). For pyometra: ceftriaxone 1 g IV daily plus metronidazole 500 mg IV 8-hourly until afebrile for 24 hours, then amoxicillin-clavulanate 625 mg oral 8-hourly to complete 7 to 10 days.
• Procedures: cervical dilatation with graduated Hegar dilators under ultrasound guidance and anaesthesia, to size 6 to 8; place a stent or Foley catheter for 1 to 2 weeks to stop reclosure; drain pyometra or haematometra; hysteroscopic resection of a fibrous ring.
• Special groups: in postmenopausal women biopsy the endometrium and canal to exclude malignancy. In infertility patients dilate before ovulation induction or intrauterine insemination.
• Red flags: fever with pelvic pain (pyometra), perforation, postmenopausal bleeding, purulent discharge, mass.
• Follow-up: review at 2 weeks and 6 weeks; ultrasound at 3 months to confirm drainage.