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  • Title: Endometrial vasculature in Norplant users: preliminary results from a hysteroscopic study.
    Author: Hickey M, Fraser I, Dwarte D, Graham S.
    Journal: Hum Reprod; 1996 Oct; 11 Suppl 2():35-44. PubMed ID: 8982744.
    Abstract:
    Long-acting progestogenic contraceptives are frequently associated with disturbances of menstrual bleeding patterns. In particular, irregular, frequent and prolonged bleeding are commonly seen. The mechanism of this irregular bleeding is unknown, but changes in the endometrial vasculature are thought to be of importance. In endometrial biopsies from Norplant users, an increase in endometrial microvascular density has been observed after 3-12 months. Morphological changes in endometrial capillaries following progestogen exposure have suggested an increase in vascular fragility. Little is known about the structure and function of the endometrial vasculature in vivo following exposure to exogenous contraceptive steroids. This study has developed techniques for the assessment of vascular fragility by imposing a mechanical stress on the endometrium and observing subsequent bleeding under direct vision. The techniques were used in a preliminary examination between 1 and 9 months after Norplant insertion, and the study identified a number of morphological and functional characteristics of Norplant-exposed endometrium. Endometrial biopsies collected from Norplant users have revealed an increase in endometrial microvascular density after 3-12 months of use. Moreover, morphologic changes in endometrial capillaries after progestogen exposure have suggested increased vascular fragility. In this study, hysteroscopy, and the attendant imposition of mechanical stress on the endometrium, was used to identify in vivo characteristics of the endometrial vasculature in 34 Norplant acceptors from Australia. A total of 24 women presented for hysteroscopy during a bleeding episode. Superficial vascularity appeared to increase as early as 1 month after Norplant insertion. Women with a relatively avascular endometrial surface experienced less bleeding than those with extensive networks of superficial vessels. Common were areas of dense vascularity adjacent to areas that appeared pale and relatively avascular. Dilated superficial vessels, observed in 1/3 of cases, were associated with more breakthrough bleeding in the previous 30 days. Unexpected was the predominance of petechiae and ecchymoses in the endometrium of Norplant users. Profuse bleeding at deflation and reflation of the uterine cavity was observed in most subjects and was also associated with an increase in breakthrough bleeding. Larger vessels appear to be the site of the breakthrough bleeding. The role of mechanical stress in the initiation of bleeding may be important in spontaneous menstrual bleeding, especially when vessels are made fragile by lack of stromal support due to progestogen-induced endometrial atrophy.
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