The Caesarean Scar Niche: What Every Woman Who’s Had a C-Section Should Know
If you've had a caesarean section and you've noticed prolonged spotting after your period, pelvic pain, or irregular bleeding that just doesn't seem right — you are not imagining it, and you are not alone.
For many women, these symptoms have a name: the caesarean scar niche.
I'm proud to share that my work on this topic has recently been published in O&G Magazine, the official journal of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. I wanted to take a moment to explain what this condition is, why it matters, and what it means for you.
So, what is a caesarean scar niche?
When you have a caesarean, your uterus is cut and then stitched back together. For most women, that heals well. But for some, the scar doesn't heal completely — leaving a small pocket or indentation in the uterine wall. This is called a caesarean scar niche.
Menstrual blood can pool in this pocket and drain slowly, which is thought to explain the spotting and bleeding many women experience long after their period should have ended.
It sounds minor. But the impact on daily life is anything but.
How common is it?
More common than most people realise. In Australia, 41% of babies are now born by caesarean — and studies suggest a niche can be detected in anywhere from 20% to over 80% of women who've had one, depending on the imaging method used.
Our own Australian research found a visible defect in 40% of women with a caesarean history who were scanned for gynaecological symptoms — and those women had nearly double the odds of prolonged periods or postmenstrual spotting compared to women with an intact scar.
The risk also increases with each subsequent caesarean. So if you've had more than one, it's worth being aware of this.
What does it feel like?
The most common symptoms are:
Postmenstrual spotting — bleeding that lingers for days after your period should have finished
Prolonged periods — research suggests affected women bleed for an average of 14 days
Pelvic pain, including pain during your period or during sex
Unexplained difficulty conceiving — emerging evidence links niches to lower IVF success rates, likely because retained blood affects the uterine environment
That said — many women with a niche have no symptoms at all and need no treatment. The concern is specifically for those who are suffering and haven't yet had answers.
Why do so many women go undiagnosed?
Partly because the niche is frequently not specifically looked for. A standard pelvic ultrasound may not pick it up unless the clinician is actively seeking it. A simple saline or gel contrast added to the scan significantly improves detection — and timing the scan to the mid-follicular phase of your cycle can also help.
But there's also a broader issue: women are often told that spotting and pain after a caesarean is simply normal. It isn't something you should just accept.
What can be done?
The good news is that this is a treatable condition.
For women not planning a pregnancy, hormonal treatment — particularly the levonorgestrel IUD — has strong evidence for improving both bleeding and pain. The combined oral contraceptive pill is another option, with studies showing a meaningful reduction in bleeding within just a few months.
When symptoms persist, or when fertility is a priority, surgical repair is an option. The approach depends on the size of the niche, but studies show improvement in bleeding for 83–93% of women treated surgically. One of my patients underwent a transvaginal repair of her scar defect and had a normal uterus with regular cycles confirmed on ultrasound four months later.
What I want you to take away from this
If you've had a caesarean — especially more than one — and you're experiencing unexplained bleeding, spotting, pelvic pain, or difficulty conceiving, please bring it up with your gynaecologist. Ask specifically about your caesarean scar.
You don't have to live with symptoms that have a name, a diagnosis, and effective treatment options.
This research matters to me because the women I see every day deserve better than being dismissed or passed from one specialist to the next without a clear answer. The caesarean scar niche is common, it is recognisable, and with the right assessment, it is manageable.
Read the Full Article: The Caesarean Scar Niche — O&G Magazine
A/Prof Talat Uppal is a specialist obstetrician and gynaecologist and the founder of Women's Health Road. She is committed to evidence-based, patient-centred women's healthcare across all life stages.
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