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Dysmenorrhea After Bilateral Tubal Ligation: A Case of Retrograde Menstruation

Morrissey, Kelly; Idriss, Nadine; Nieman, Lynnette MD; Winkel, Craig MD; Stratton, Pamela MD

Case Reports

BACKGROUND Endometriosis, arising de novo, is believed to be uncommon in women who have undergone bilateral tubal ligation because the occluded tube prevents outflow of blood and menses.

CASE A woman 10-year status-post bilateral tubal ligation suffered from dysmenorrhea and menorrhagia that began within 1 year after sterilization. At the time of bilateral tubal ligation, no endometriosis was observed. A recent magnetic resonance imaging scan showed no pelvic abnormalities, and the patient underwent a diagnostic laparoscopy in anticipation of finding endometriosis, yet none was found. At laparoscopy performed on day 3 of her menstrual cycle, the proximal segments of her occluded fallopian tubes were dilated with blood. As this was the only abnormality found, we postulated that her dysmenorrhea might be related to the dilated proximal tubal stumps. We evacuated the bloody fluid and occluded the proximal tube at the cornua with Filshie clips. One year after surgery, the patient remains asymptomatic.

CONCLUSION This case is unique because bilateral tubal ligation combined with retrograde menstrual flow appears to have caused dysmenorrhea. Women who have undergone tubal ligation and who have dysmenorrhea may benefit from a diagnostic laparoscopy during menstruation to evaluate the possibility of retrograde menstruation dilating the proximal tubal stumps.

Retrograde menstruation and dilatation of proximal tubal segments with blood after bilateral tubal ligation can cause dysmenorrhea and pelvic pain that mimics the symptoms of endometriosis.

Pediatric and Reproductive Endocrinology Branch, National Institute of Child Health and Human Development, Bethesda, Maryland; and Georgetown University Medical Center, Washington, District of Columbia

Address reprint requests to: Pamela Stratton, MD, National Institute of Child Health & Human Development, Pediatric and Reproductive Endocrinology Branch, Chief, Gynecology Consult Service, 10 Center Drive, MSC 1583, Building 10, Room 9D42, Bethesda, MD 20892-1583; E-mail:

Received October 31, 2001. Received in revised form January 17, 2002. Accepted February 7, 2002.

© 2002 The American College of Obstetricians and Gynecologists