Isthmocele

What it is

An isthmocele is a healing defect in the uterine wall at the site of a C-section scar, forming a small niche or pouch in the isthmus. Menstrual blood collects there and drains slowly, causing dark bleeding that lingers after the period, pelvic pain, and, in some cases, difficulty conceiving, because the buildup of blood and mucus alters the environment inside the uterine cavity. The condition is common in women who have had one or more C-sections, although many have no symptoms. The gynecology team at Femi Saúde diagnoses isthmocele with ultrasound and hysteroscopy and recommends correction when there are symptoms or a desire for pregnancy.

Most common symptoms

• Dark bleeding that lingers for days after your period
• A period that seems like it never ends
• Pelvic pain and cramping outside your period
• Pain during intercourse
• Difficulty conceiving after a C-section
• No symptoms, found incidentally on ultrasound

Causes and risk factors

• C-section, especially when repeated
• A low uterine incision, close to the cervix
• C-section performed during advanced labor
• Suturing technique and poor healing
• A retroverted uterus, which hinders drainage

How it is diagnosed

Suspicion arises from a history of C-section and the bleeding pattern, which continues with dark blood after the main flow. Transvaginal ultrasound, preferably right after the period, shows the niche in the scar and measures its depth and the thickness of the remaining uterine muscle over it, information that guides the type of correction. Saline-infusion sonohysterography, with fluid inside the uterus, improves visualization. Diagnostic hysteroscopy confirms the defect, assesses the accumulated content, and rules out other causes of bleeding, such as polyps. MRI is reserved for selected cases.

How we treat it at Femi Saúde

Isthmoceles without symptoms are generally just monitored. When there's prolonged bleeding or pain, the gynecology team at Femi Saúde may start with hormonal contraceptives, which reduce flow and buildup in the niche. Correction by surgical hysteroscopy is the most commonly used option: it smooths the edges of the niche so blood can drain, with quick recovery, and is indicated when the uterine wall over the defect is thick enough. For deep niches with a thin wall, or when a future pregnancy is desired, correction by laparoscopy rebuilds the uterine wall. The plan is individualized according to symptoms and reproductive plans.

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