Women's Health Community

Dear PsychosomaticPA: Most commonly, when we send such specimens to the lab, the report returns as: white blood cells, red blood cells, fibrin, and other components of uterine lining tissue. It can look different as it is more solid that the liver-like consistence of blood clots. Many women worry that this is linked to a missed miscarriage, but that is not the usual explanation. If this is a concern than a sensitive pregnancy test can be done.

VERY rarely a woman will pass a "uterine cast" also known as "decidual cast" (like decidual tissue of the uterine lining). This is when the lining is passed as a triangular shaped bit of tissue similar to the shape of the inside of the uterus. The predisposing condition for passing a uterine cast is abrupt cessation of high dose progesterone therapy. I have also seen a cast associated with an ectopic/tubal pregnancy. Here are two citations on this from the National Library of Medicine site:

J Pediatr Adolesc Gynecol. 2007 Jun;20(3):191-4. Links Decidual cast in a girl receiving depot medroxyprogesterone acetate--a case report.Singh V, Talib N, Strickland J. Departments of Pathology, Pediatrics, and Gynecological Surgery, Children's Mercy Hospital, Kansas City, Missouri 64108, USA. [email protected]

BACKGROUND: The passage of tissue per vaginam in a young girl raises several diagnostic considerations that include aborted pregnancy, benign polyp, rhabdomyosarcoma, and rarely decidual cast. CASE: A 9-yr-old girl who was receiving depot medroxy-progesterone acetate to suppress menstruation passed tissue per vaginam. Pathological examination of the tissue showed a decidual cast with no chorionic villi, while a serum hCG test was also negative. CONCLUSIONS: Decidual cast formation is a rare side effect of progestogen use and should be considered in the differential diagnosis of passage of tissue per vaginam.

Obstet Gynecol. 2010 Aug;116 Suppl 2:488-90.
Membranous dysmenorrhea: a complication of treatment for endometriosis.

Appelbaum H.

Department of Obstetrics and Gynecology, Division of Pediatric and Adolescent Gynecology, Long Island Jewish Medical Center/Steven and Alexandra Cohen Children's Medical Center of New York, USA. [email protected]
Abstract

BACKGROUND: Progesterones are frequently used to treat endometriosis. Exaggerated response of the endometrium to high levels of progesterone can result in a decidualization reaction. Decidualization may cause an exacerbation of symptoms of dysmenorrhea associated with endometriosis.

CASE: A 16-year-old girl with uterine didelphys and obstructed hemivagina presented with irregular bleeding and severe abdominal cramping after resection of the vaginal septum. Persistent endometriosis treated with norethindrone acetate resulted in severe colicky abdominal pain and expulsion of a decidual cast.

CONCLUSION: Membranous dysmenorrhea can occur in response to excess progesterones. An understanding of the physiologic response of the endometrium to treatment will guide us to a high clinical suspicion of this rare entity when symptoms worsen in response to progesteronal treatment for endometriosis.

Bottom line, I would wonder if you had endometriosis or adenomyosis as a part of the severe cramps.

Yours,
Jane

Thanks for the reply.

Although I am not on hormonal therapy, I am quite certain these are casts I am passing. They are triangular, purplish-gray, thin, and absolutely nothing like blood clots. Trust me... I've seen plenty of those, too.

My periods are really quite short and light. I only pass one "cast" per period. I'll spot lightly for a few hours or a day, then get really bad cramps for several hours, then pass one of these things, then bleed moderately (and painlessly) for a day or two, then I'm done. It makes perfect sense to me.

Funny that you don't believe me either...

Dear PsychosomaticPA: Oh no, I do believe you. That triangular shape is classic for a desidual cast. It's just not very common to have this every month. I would hope that your GYN would send it to pathology and then write you up as a case report for publication. That's how we expand our knowledge about what is possible. Many of the other cast reports are about a single patient as well.

Yours,
Jane

Hi Psychosomatic PA, I also experienced something like this yesterday. I have just finished my first month of birth control (Loestrin24Fe), and the evening of the first non-hormone day I started getting cramps, so I knew my period would start the next day. The next day the cramps increased to an unbearable level...2 extra strength tylenol and 600 mg of ibuprofen later, no effect. The next hour and a half I had spasmodic cramps that had me curled in a fetal position on the floor. The only thing that got me up was I had to go to a party and I thought I'd just bear the pain and hope the analgesics would kick in by the time I got to the party. Fortunately the pain did subside. At the party, however, I went to the bathroom and discovered the largest piece of tissue that I had ever seen come out of me, have no idea how that thing fit through my cervical os! I did some research when I got home and I now believe it was a uterine/decidual cast. I have read that combination oral contraceptives can very rarely cause these, so I am most likely going to go off of the Loestrin as I can not handle this happening on a regular basis. Will talk to my doc about it this week and see if she knows of any other remedy for this other than stopping the pill...I've read that sometimes different doses can fix the problem, so I wonder if a high dose of a birth control pill would help you? You might try a different gynecologist for sure though, if yours laughed at you...definitely not professional demeanor!
-Lauren

I was reading this post and thought it was interesting that someone else is going through what I go through every month. I just like PsychosomaticPA have this occurrence with each menstrual cycle. I begin with about one day of light bleeding, day 2 I start cramping. This cramping is constant and increases in intensity to the point of being in severe pain. I pray every month that when this is about to happen I am home rather than at work or out since I need to lay down to handle the pain. This severe cramping lasts anywhere from 3-6 hours. Then I feel the passing of the tissue. Once that happens thankfully the pain is gone. Menstruation for me lasts about 7-9 days. After passing the cast I spend quite a few days with moderate to heavy bleeding. I have had this since I was young however it was not until about a year ago that it started coming out in one complete piece, before that it would come out in large sections. Like the other person with this, it never fails every month I go through the same thing. My GYN knows about the massive cramping and heavy bleeding but I always felt weird telling him about passing the cast. I am an ER Trauma Nurse and to me its not a big deal, it takes a lot for me to go to a doctor and I usually brush off anything not life threatening.

I've been searching for years for information on this. I am 45, and have never had children. I went through reproductive testing (hormones, hysterosalpingogram, ultrasounds) in my mid-to-late 30s - all normal - and tried intra-uterine insemination with donor sperm about 20 times, but no luck. The docs were baffled. I never tried any drugs (although they were offered) to help me conceive, as there was nothing they could find wrong with me. I've since given up the idea of having children unless some miracle happens (my husband's fertility has now improved, but as I say, I'm 45).

My periods have always been regular, but ever since they started when I was 12, a few hours after the period started, I would have 3-6 hours of horrible pain that no painkiller could touch. It's true that you have to lie down just to get through it. It's the kind of pain that causes a cold sweat over your whole body. After a few hours I would have an especially excruciating cramp and feel something pass, and the pain would subside. What I pass every month is not a clot - it's a blob of membrane. If I tease it out with my fingers (not squeamish!) it's probably about 2 inches across. It usually comes out whole, but sometimes in pieces.

I realize that clots can seem solid and liver-ish. I have those too - everyone does I guess. But I also pass this blob of membrane, which is something quite different.

The only time this didn't happen was during my 20s for a while when I was on the Pill.

I've always wondered if this unusual menstruation was related to the fact I've never conceived. Anyone have any insight into this?
Thanks!
~Wendy

I have the same problem each month. I have tried to be pregnant a half year , but i can`t. I used medroxyprogesteron-acetat in 4 months.but doesn`t help. My doctor means that in autumn I will have a hysteroscopi.Please answer how are you, can you have a baby?

Are you wanting a reply from me, or someone else?

To answer your questions, I have perfectly normal periods most months, but 2-4 times per year, I have HORRID cramps (like, dry-heaving over the toilet because of the pain)... and those are the periods where I pass a sheet of tissue.

I am single and have never attempted to become pregnant, but I'm fairly certain that this should not affect a woman's fertility.

Hi! Thanks you for your answer. I believe you, I have the same pains, I sit on the toilet, cramps, I cannot do anything, only wait and cry on the toilet, and wait at this tissue passes. When I was 16, doctors didn t believe me. They said to my mother, that I have made sex and this is spontan abort. I didnt have sex because I was single until I was 26 years old. Doctors said after this taht this was endometrium from the uterus. After this I had genetics examination because I have an other problem with my eye, (conjunctivitis lignosa). I have plasminogen deficiency, my doctor sais that s why I have these tissues come out every month and I have to get fresh frosen plasma from a healthy person. In the last 3 months this tissue didn t come out. My doctor can see on ultrasound that it is in . Thats why I will have hysteroscopi and laparoscopi 22.september. I have afraid that I cannot be pregnant. Please answer for me, how old are you? Do you have a good gynecologist? I think you also have to speak with a genetics laboratory.I am 28 years old. Thank you if you believe me.

I am now 27. This does not happen every month - just about 3 times per year. Because I have been uninsured since January, I do not have a gynecologist (or any doctor, for that matter). I highly doubt I have any genetic problems...

Ok, so I just started searching information on this. The last time this happened to me was 7 years ago, before I concieved my first daughter. I hadnt done it since, and have had 3 beautiful girls, so obviously it doesnt affect being able to get pregnant, and we are planning more children.
It happened to me agian today. This is my first period in 2 1/2 years. Or at least my first period since getting pregnant with my youngest. I breast fed so didnt get my period, then I went on 3 months of birth control so that explains why no periods for so long.
Since this first started happening my periods are very light. Now that I passed the cast I have a super heavy flow. My cramps when getting ready to pass the cast were similar to the start of labor. Definitly not painful to the point they used to be, but still no picnic. Guessing having kids has something to do with the lessening of pain.
Interesting part... this isnt 1 single triangular piece. Its a full cast, meaning its more like a pouch and there are 2 triangular pieces connected together. Obviously the entire uterine lining came off at once in one piece. I am also throwing lots of clots now. The weird thing though is what is on/attatched to the inside of the cast. There are white chunks of tissue, different from the cast. I had some major infections after my daughter was born, so I wonder if those are left over pieces of placenta. The only problem with that is I would think they would cause infection. But.. I have been on antibiotics several times in the last 10 months so maybe that prevented further infection?
Question for anyone who has had these issues... did anyone else end up with pain during sex after it started happening? I did for all the time it was happening before, and since my last child was born, and obviously things were started and leading up to the cast today.....
Any professionals with ideas on this too?
Anyways, I hope to be pregnant agian soon so hopefully this issue will go away for another few years, and I swear when we feel we are done having kids, I might go with a partial histerectomy to prevent any other further issues.

How did your test go? I am curious to what they said. I dont know about your gentic issues, but I have 3 kids, and you can read my other post to see what I have gone through. I just want you to know not to worry too much. I have 3 girls all concieved AFTER this started happening to me

Hi!
Thank you for your answer. There was hysteroscopi and laparoscopi on the last Thursday. My doctor wrote:
The whole uterine cavine is covered with thin adhesions in all directions. Doctors tried to inject methylene blue through the cervix. No fluid passes out to the tubes or the cavity. Conclude that the tubes are blocked in the medial ends on both side. Uterine adhesions is known to be part of the Plasminogen deficiency syndrom. Infertility is also an issue. I cannot be pregnant naturally method, we can try with in vitro fertilisation, but doctors said that isn t much hope because of the whole uterni cavity is covered with adhesions.
Thank you for your answer.

Since coming into my 40's I have been experiencing exactly the same thing. I told doctors that I had chunks of flesh coming out of me, after excruciating cramps. Once they passed, the period continued without any significant problem. The doctors all said that it was probably just clotting, and with the changing of my hormones (perimenopausal) thicker clotting was normal. I tried to explain that it was not clotting, but it fell on deaf ears. I am now 47 and I started to have periods every two weeks. Because of this my doctor suggested that I go on birth control pills to help stabilize my crazy hormones. I agreed to try. I was put on Seasonale birth control, which should have abated periods for 3 months at a time. After 2 weeks I began to spot, which was normal I was told. After 2 more weeks I woke up to excruciating pain. Having had a kidney stone before, I thought perhaps I was having another one. My husband had some left over Oxycodone after having his molar pulled, put it barely touched the pain. I stayed in bed taking ibuprophin and oxycodone alternately for several hours. By early evening the pain was tolerable enough to get up and walk around. After 30 minutes the cramping began again, and I felt a gush of blood and ran to the bathroom just in time time catch what appeared to be a large piece of tissue. I showed my husband, and he said grab it and take it to the doctor. They could no longer deny that it was flesh, and not a blood clot. They referred me to an OBGYN and tested me for cancer, which came out negative, and suggested that I have an Endometrial Ablation. Hopefully soon I will no longer have to experience another painful episode like that one. I also discontinued the birth control. Endometrial Ablations are only an option for women that do not want to have anymore children.