Hematometrocolpos is a rare but treatable condition in which menstrual blood gets trapped between the uterus and the vagina, and the reason a delayed period should never be ignored.
In 2021, Chebet* presented to the casualty department with severe lower abdominal pain, abdominal swelling and difficulty passing stool that had lasted two days. On further inquiry, she revealed that she had not yet attained menarche, her first menstrual period.
In clinical practice, any woman of reproductive age presenting with abdominal pain is considered pregnant until proven otherwise. Chebet, 13, tested negative for pregnancy, but her pelvic scan revealed hematometrocolpos, a condition in which menstrual blood becomes trapped in the body with nowhere to go.
A year later, a similar case arrived at the hospital: a 14-year-old girl brought in by her mother. She was the youngest of three sisters, and while her two elder sisters had both reached menarche at 13, she had not yet had her first period.
Though she had no symptoms, her worried family sought medical advice, a decision that proved important. Her pelvic scan findings mirrored Chebet’s.
On examination, both girls were found to have an imperforate hymen, a thin membrane blocking the vaginal opening, and both required hymenotomy, a surgical incision to open it. They were discharged once the effects of spinal anaesthesia had worn off and their pain was under control, with a follow-up visit scheduled a month later to confirm normal menstrual flow.
While some girls develop puberty as early as eight, others may not show signs until they’re 13
For most girls, a first period is an important milestone. For a few, like Chebet and the 14-year-old, that milestone never truly arrives, not because menstruation has not begun, but because it becomes trapped inside the body with nowhere to go.
Puberty does not occur at the same age in all girls. While some begin developing as early as eight, others may not show signs until they are 13, with breast development generally the first visible sign.
Menarche typically follows two to three years later, with the next period arriving anywhere from 21 to 45 days after, though longer intervals are normal in the first two to three years as the body continues developing. Some girls, however, reach the upper limit of the expected age without ever experiencing a first period, as Chebet and the 14-year-old both did.
What is Hematometrocolpos?
It is a rare condition in which menstrual blood becomes trapped in both the uterus and vagina because the normal outflow is blocked, a period with no exit. In related conditions, blood may accumulate solely in the uterus or vagina, depending on where the reproductive tract is obstructed.
What are the symptoms?
Some patients seek medical attention because of symptoms, as Chebet did, while others are identified simply because they have not started menstruating by the expected age, as with the 14-year-old girl.
Symptoms often do not appear immediately, developing instead over several menstrual cycles as blood accumulates in the vagina and uterus.
This causes distension and pressure on surrounding organs, resulting in lower abdominal pain that comes and goes at regular intervals, abdominal swelling, difficulty passing urine, hard stools and lower back pain.
What causes Hematometrocolpos?
The causes are mainly congenital, present from birth, and include:
- An imperforate hymen, the most common cause, accounting for approximately 90 per cent of cases
- Vaginal atresia, a birth anomaly in which the vagina is partially or completely blocked or fails to develop normally
- A transverse vaginal septum, in which a wall of tissue forms across the middle or lower part of the vagina
According to the National Institutes of Health (NIH), imperforate hymen occurs in about 1 in 2,000 females, with reported prevalence among term newborns ranging from 0.014 per cent to 0.1 per cent. Patients may remain undiagnosed until menarche, as in the cases above, although the anomaly can occasionally be detected in infancy.
What happens when Hematometrocolpos goes untreated?
As menstrual blood accumulates, it may flow back into the pelvis, contributing to endometriosis, a condition in which tissue similar to the uterine lining grows outside the uterus.
This can cause chronic pelvic pain, reduce fertility, make passing stool difficult, and, in severe cases, block the flow of urine. Left untreated, prolonged urinary blockage can damage the kidneys.
How can Hematometrocolpos affect mental health?
This condition affects psychological well-being both before and after diagnosis. Before diagnosis, many girls suffer low self-esteem, especially if they have not started menstruating while their peers have.
They fear the unknown, worry about future fertility, and experience stress and frustration due to repeated hospital visits, delayed diagnosis, and unexplained abdominal pain. After diagnosis, they may worry about the condition recurring and its effects on future sexual function.
What is the impact of delayed diagnosis?
Delayed diagnosis may worsen mental health. Chronic cyclic pain and uncertainty can contribute to anxiety and depressive disorders, reduced school attendance, lower academic performance, and reduced social participation among adolescents.
To address this, prompt diagnosis and treatment should be paired with counselling about the condition and its prognosis, along with psychological support for those experiencing significant anxiety or depression. Where necessary, referral to mental health professionals should be considered.
How is Hematometrocolpos treated?
Despite differing underlying causes, surgical treatment remains the cornerstone of management, though the specific procedure depends entirely on the cause. An imperforate hymen requires removal of excess hymenal tissue; a transverse vaginal septum requires removal of the septum followed by vaginal reconstruction; narrowing of the cervical opening requires widening of the cervix; and a vagina that failed to develop or is closed requires surgery to create or rebuild it and establish a normal opening.
After any of these procedures, accumulated blood is drained gradually, pain is relieved, and any infection is treated. Follow-up care then ensures symptoms resolve and normal menstrual flow is established.
Although rare, Hematometrocolpos can easily be overlooked because its symptoms are often vague and nonspecific. Parents, caregivers, clinicians, and adolescent girls should recognise that the absence of a first period, with or without other symptoms, warrants medical evaluation. Early recognition, along with open conversation about adolescent reproductive health, can turn a crisis into a routine fix.
Dr Rachel Kerubo is the Resident Medical Officer, Department of Internal Medicine, Nyamira County Referral Hospital.
