White leopard skin pattern at hysteroscopy in a case of hematometra

.A 42 year old patient with a history of abnormal uterine bleeding and chronic anemia was referred to the Department of Obstetrics and Gynecology of Sapienza University of Rome for evaluation. She had menomethrorragia for several years, with a recent switch to painful, herratic bleeding. She had previously undergone two cesarean sections. At transvaginal ultrasound, the endometrial cavity appeared partially distended by a hypoechoic fluid collection, diagnosed by an expert sonographist as a partial hematometra. There was also sonographic evidence of isthmocele, with no other abnormal finding. Panoramic hysteroscopy confirmed the presence of isthmocele, and of a normally shaped uterine cavity, partially distended by a brownish fluid collection. After rinsing of the cavity for complete evacuation of the fluid colelction, the endometrial epithelium appeared whitish, with black spots, rings, and spirals (figure 1), resembling the coat of a white leopard (figure 2). Histology revealed the presence of normal endometrial glands, distended by blood material (figure 3, hematoxilin-eosin, magnification 100X). This hysteroscopic finding, that can be encountered in case of hematometra, can be defined as “white leopard skin pattern”.