(52) Hysteroscopic metroplasty for use of intrauterine devices in adolescents and young adults

Background: There is no published literature on the use of hysteroscopic metroplasty in an adolescent or young adult (AYA) population, nor for the indication of desired intrauterine device (IUD) usage. We aimed to describe the usage of this procedure, which has historically been performed for reproductive concerns, in AYA with uterine septa who desired IUD insertion for dysmenorrhea, contraception, and heavy menstrual bleeding (HMB).

Case: All patients presented were diagnosed with a uterine septum when evaluating for a possible malpositioned IUD, and had either trialed systemic hormone management or had medical restrictions on hormonal treatment options. All previously placed IUDs were removed prior to surgical management. All metroplasties were performed using a bipolar Twizzle Tip electrode to incise the septum and all patients had uncomplicated placement of a 52-mcg IUD at time of metroplasty.

A 15-year-old G0 with dysmenorrhea desired a hormonal IUD after failing combined hormonal methods. Her complete uterine septum was diagnosed via ultrasound after a string check raised concerns for a low-lying IUD. After counseling, she desired surgical removal of her septum to be eligible for repeat placement. After uncomplicated septum resection and IUD placement, she was seen for a one month post-operative visit without any reported irregular bleeding or pelvic pain.

A 17-year-old G0 presented for HMB and dysmenorrhea. Her medical history included juvenile idiopathic arthritis and migraines with aura. After IUD placement, she underwent abdominal imaging for a weight loss work-up that noted a malpositioned IUD and uterine septum. After repeat counseling on available methods, she maintained that an IUD was best for her menstrual management. She underwent an uncomplicated septum resection and IUD placement, and was seen for follow-up at two months without further menstrual complaints.

A 25-year-old G1P0010 with dysmenorrhea and HMB, with failure of two hormonal methods, had worsening dysmenorrhea after IUD placement. Pelvic imaging revealed a complete uterine septum with divergence of the lower segment into two separate cervixes. She underwent uncomplicated resection and IUD placement, as well as a laparoscopy to evaluate her dysmenorrhea. She was seen two months post-operatively with a significant improvement in menstrual symptoms.

Comments: This case series highlights the importance of metroplasty as a consideration for patients for whom an IUD is the preferential or only treatment option for a variety of gynecologic indications, especially for those unable to use other hormonal therapies secondary to side effects or co-existing conditions.