Osteoid Endometrial Metaplasia in
Postabortion: About Three Cases at the National Hospital Center of Pikine; Dakar, Senegal
Moussa Diallo*, Khalifa Ababacar Gueye, Abdoul Aziz Diouf, Astou Coly Niassy Diallo, Fatoumata Bineta Diallo, Daba Diop, Ndeye Astou Faye, Khalifa Fall, Youssoupha Touré, Codou Sene Seck, Anna Dia Diop, Jacques Raiga and Alassane Diouf
Service de Gynécologie-Obstétrique, Centre Hospitalier National de Pikine, Sénégal
Submission: June 11, 2019; Published: June 19, 2019
*Corresponding author: Moussa Diallo, Service de Gynécologie - Obstétrique, Centre Hospitalier National de Pikine, Sénégal
How to cite this article: Moussa D, Khalifa A G, Abdoul A D, Astou C N D, Fatoumata B D, et al. Osteoid Endometrial Metaplasia in Postabortion: About Three Cases at the National Hospital Center of Pikine; Dakar, Senegal. J Gynecol Women’s Health. 2019: 15(4): 555917. DOI: 10.19080/JGWH.2019.15.555917
Osteoid metaplasia of the endometrium is a condition characterized by the presence of ectopic bone tissue within the endometrium . It is a rare condition that most often occurs following an interrupted pregnancy. However, its physiopathology still knows some grey areas. Its discovery is most often fortuitous during a secondary infertility check-up in a past interrupted pregnancy; the most frequent circumstance but it can be at the origin of metrorrhagia, dyspareunia, leucorrhoea. These different symptoms are part of chronic aseptic endometritis. We are reporting here, three recently diagnosed cases in our department and using a literature review, we will detail the pathophysiology, symptomatology and management of this pathology.
Endometrial osteoid metaplasia refers to the presence in the endometrium of ectopic bone tissue of mainly fetal origin [1,2]. It was first described by Mayer in 1901 and its incidence is estimated at 0.3 per 1000 infertile women . However, the underestimation of its incidence remains highly probable because it is a little known, under-diagnosed and insufficiently researched pathology. Its diagnosis is based on diagnostic hysteroscopy (with histological examination of the surgical specimen) and its treatment on complete resection during surgical hysteroscopy. Thus, we are reporting here three cases recently handled in our department.
Mrs. S. B. primigravida nullipara, 41 years old, had consulted for cycle disorders such as menstrual irregularity and minimal metrorrhagia that had progressed over the past few months. Her history includes a voluntary termination of pregnancy at the age of 17 years, the gestational age of which was unknown, and primary infertility of the 13-year-old. The clinical examination found a soft abdomen with no palpable mass. The gynaecological examination finds an endo-uterine bleeding made of red blood with clots of low abundance and a macroscopically healthy cer
vix. The vaginal touch returned to a normal-sized uterus. The biological check-up had returned normal and the cervical smear was normal. Pelvic ultrasound had revealed an intrauterine, oval, fundic hyperechogenic image of 15mm of major axis, poorly limited with posterior attenuation (posterior shadow cone) (Figure 1).
An operative hysteroscopy with general anaesthesia has
been proposed. The latter, carried out, had revealed a friable,
whitish tissue fragment reminiscent of bone tissue (Figure 2).
This fragment, with irregular edges, was firmly attached to a
macroscopically healthy uterine mucosa. Its total removal had
been done without incident with satisfactory hemostasis. Histological
examination of the slices sent in this way had bone tissue
fragments made of necrotic spans with disinhabited osteolytic
deficiencies with intertrabecular spaces occupied by eosinophilic
serosity. The pathologist therefore concluded that there was
endometrial ossification and therefore osteoid metaplasia.
She was a 23-year-old primigravida nullipara patient with
menstrual disorders. In her history, there was a miscarriage five
years ago, for which she would have had intrauterine aspiration
and then medical treatment for incomplete uterine evacuation.
The patient’s clinical examination was strictly normal at admission
except for minimal uterine bleeding. The gynaecological
ultrasound then performed, objectified a hyperechogeniic endometrium
with a strong posterior attenuation over the entire
body portion (Figure 3). Its thickness was 12mm. In front of this
table, an osteoid metaplasia of the endometrium was suspected.
A hysteroscopy performed objectified a cervical canal that
was partially blocked by incomplete synechia. At the level of the
uterine body, there were many whitish elements, sometimes in
budding form (Figure 4), sometimes in tubular form (Figure 5),
many of which creaked under the biopsy forceps. A complete
uterine evacuation was performed. Histological examination of
the specimen confirmed the diagnosis of endometrial osteoid
It was a 29-year-old patient, primiparous with two abortions,
who was followed for secondary infertility of the 12-month couple
and metrorrhagia. In its history, there was an early abortion
that was managed by vaginal administration of misoprostol. No
control ultrasound had been performed, as the bleeding had
spontaneously faded and uterine evacuation was considered
complete. Five months after this episode, she presents metrorrhagia
that rebelled against medical treatment. An ultrasound
examination had then revealed a hyperechogenic (Figure 3) endometrium
at the bottom of the uterus; the myometrium being
normal. A hysteroscopy performed had shown a highly suspicious
appearance of endometrial osteoid metaplasia (Figure 6). The management consisted of evacuation with the hysteroscopy
clamp (Figure 7). Once again, the histological examination confirmed
the diagnosis of endometrial osteoid metaplasia.
Our observation once again shows the diagnostic difficulties
of osteoid metaplasia both clinically and paraclinically. Diagnostic
and surgical hysteroscopy remain the reference for its diagnosis
and management. In our observation, infertility, menstrual
cycle disorders and metrorrhagia remained the main reasons for
consultation. On the other hand, secondary infertility and chronic
pelvic algae in relation to chronic aseptic endometritis remain
the main circumstances of discovery, although the literature has
reported other possible clinical manifestations such as leucorrhoea,
dyspareunia and algomenorrhoea [4,5].
The questioning almost always includes the notion of termination
of pregnancy followed by endouterine manoeuvres
that can precede the diagnosis by a few months to several years.
We first used pelvic ultrasound to support our diagnosis, which
showed a hyperechogenic, intrauterine, irregular image with a
posterior shadow cone of difficult interpretation. This intracavitary
hyperechogenic picture is constantly described as a contrasting
feature with their shape and size, which may suggest
other diagnoses ranging from architectural changes (myomas
or calcified polyp) to intrauterine foreign bodies (intrauterine
device). Hysterography is often normal due to the close radiographic
opacity between the lesion and the contrast medium; its
diagnostic contribution is discussed .
Diagnostic hysteroscopy is probably the key examination to
evoke the diagnosis with the identification of whitish, friable and
easily detachable bone tissue from the endometrium. The literature
reports several different aspects of hysteroscopy :
a) irregular, serrated, tangled, whitish-coloured bone
chips with a crab or egg shell appearance,
b) opacification plates embedded in the deep endometrium
in contact with the myometrium,
c) small bones sometimes recognizable (shoulder blades,
Hysteroscopy allows, in addition to diagnosis, the removal of
bone fragments, which must be carried out with caution in order
not to perforate the uterus. This risk should be assessed on ultrasound
by measuring the myometrial thickness separating bone
tissue from the uterine serosa. Some authors even recommend
performing surgical hysteroscopy under ultrasound control in
order to simultaneously visualize the uterine and pelvic cavities,
thus ensuring a controlled intervention .
In our observation, the notion of termination of pregnancy
several years before the appearance of clinical manifestations
leads us to believe that the fetus origin is due to incomplete
uterine evacuation, but the pathophysiology remains that of the
hypotheses. Finally, it should be noted that genital or extragenital
ectopic ossification is not uncommon. It is an entity that can
sit in all organs (heart, lungs, joints, vessels...). This ossification
always occurs within an inflammatory tissue (chronic inflammation
most often). It is therefore likely that, similarly, the retention
of trophoblast, deciduous or even decidualized mucosa, can create
local conditions within an inflammatory endometrium that
are conducive to osteoblastic development .
Endometrial osteoid metaplasia is a rare and often unknown
condition. Its diagnosis must be evoked in front of any evocative
context: secondary infertility with the notion of pregnancy interrupted
regardless of the associated clinical manifestations. Its
pathophysiology still knows some grey areas and allows the possibility
of recurrence to be considered, hence the need for complete
resection of the bone parts and post-operative follow-up.
Hysteroscopy remains the key to diagnosis and management.