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Endometriosis Where?!?
Although very rare, endometriosis can show up in surprising places. Here are a few case studies:
Vaginal Cuff
“A 53-year-old female presented with postmenopausal bleeding. She had undergone a total TAH/BSO in 2001 for menorrhagia and uterine fibroids. The operative report described an uncomplicated procedure, and pathology was remarkable for inactive endometrium, adenomyosis, small fibroids, and normal ovaries, without evidence of endometriosis. Since then, the patient had used oral estrogen replacement. On presentation, ultrasonography showed no pelvic masses or fluid collections. She did have vaginal cuff granulation tissue and tenderness on bimanual examination. A vaginal cuff biopsy revealed endometriosis with simple hyperplasia without atypia. The patient elected to have laparoscopic vaginal cuff revision with removal of the vaginal cuff endometriosis that was demarcated by injectable dye as a guide. Results: The patient’s postoperative recovery was uneventful. No bleeding or pain was noted during a 2-year follow-up period. She was not restarted on estrogen replacement to minimize the risk of recurrence. Conclusions: Laparoscopic vaginal cuff revision with the use of injectable dye to ensure complete excision of cuff endometriosis is a feasible and safe method for the management of symptomatic vaginal cuff lesions following hysterectomy.”
Inguinal Hernia
“A 20 year old nulliparous female presented with a right sided inguinal lump, her pain and swelling worse during menstruation. She had no other previous surgical or medical history. The mass was non-reducible with features of a femoral hernia. Ultrasound reported a lobulated hypoechoic fluid filled structure within the inguinal canal above the superficial ring. Further imaging modalities were considered but not deemed suitable in this particular case with consideration of future fertility. Based on clinical findings suspecting groin hernia, the patient underwent laparoscopic mesh repair of hernia. Surgery confirmed a right side indirect inguinal hernia arising from a patent indirect sac. The sac was reduced with traction and on routine transection chocolate brown fluid escaped. Mesh was placed in the pre-peritoneal plane over the defect to complete the hernorrhaphy. Histopathology of sac and cystic contents showed an inguinal hernia sac with endometriosis. Her postoperative recovery was unremarkable.”
Lungs (Pulmonary):
“Sixty-five cases of pulmonary endometriosis are reviewed for characteristics of age, parity, prior surgery, prior endometriosis, location of pulmonary disease, and documentation of disease. Two categories of pulmonary endometriosis are defined: 1) pleural and 2) parenchymal. Age, history of pelvic endometriosis, and location of disease were found to be significantly different between the 2 groups.”
Liver (Hepatic):
“Here, we present a case of an incidental intraparenchymal hepatic endometriosis in a young woman who presented with only right upper quadrant pain. A 25-year-old nulliparous woman was referred to our unit due to an 8-month history of relapsing and remitting right upper quadrant pain. In the last month, these episodes occurred more often and were related to the ingestion of fatty foods. There were no other symptoms.”
Skin (Cutaneous):
“A clinicopathologic study of cutaneous endometriosis in 82 patients includes 28 lesions of the umbilicus, 42 of the lower abdominal wall, and 12 in the inguinal area, labia, and perineum. With the exception of five endometriomas of the inguinal area, every lesion occurred in a scar. Twenty-one arose without a preceding operation in the physiologic scar of the umbilicus, and 56 in surgical scars. The umbilical lesions were too precisely located to be logically explained by lymphatic spread, unless only the cells that find scar tissue are able to proliferate. Cesarean-section scars of 26 patients were involved, indicating a vastly greater incidence of endometriosis in cesarean scars than previously reported. This either casts doubt on the theory of transplantation as the usual pathogenetic mechanism for the lesions in surgical scars, or suggests that the endometrium of pregnancy is easier to transplant than is commonly believed.”
Sciatic Nerve:
“Endometriosis (EN) is a common gynecological condition characterized by the presence of functional endometrium located outside the uterine cavity. Sciatic nerve (SN) is rarely affected by EN. Magnetic resonance imaging allows a direct visualization of the spinal and SN, and it is the modality of choice for the study of SN involvement in extrapelvic EN. We report a case of an endometrioma located in the right SN with a systematic review of the literature.”
“A 35-year-old female patient consulted for right low back pain extending along her posterior thigh, calf and foot since 2 years. The pain was recurrent, acute in onset, lasted several days and gradually diminished until disappearing. It was refractory to common analgesics and during the crisis she had difficulties to walk. Neurologist requested a calendar of pain in which the relationship between the menstrual cycle and the pain became evidenced. We performed MRN of the lumbo sacral plexus that showed multiple endometriotic implants in ovaries, L5-S1 roots and a huge one on the sciatic nerve (intra and extrapelvic segment). The patient started oral contraceptives but presented progressive worsening of pain until it became constant and developed step page. Electromyogram showed acute and chronic axonal damage in the sciatic nerve distribution. Medical treatment was changed to leuprolide acetate. The patient evolved with improvement of ovarian endometriosis but persistence of sciatic nerve lesions, leg pain and weakness up to now. Surgical option was considered.”
“A 20-year-old woman presented with complaints of severe dysmenorrhea lasting for more than 6 years and dysfunction of her left lower limb lasting for approximately 4 months. Both CT and MRI demonstrated a suspected intrapelvic and extrapelvic endometriotic cyst (7.3 cm × 8.1 cm × 6.5 cm) passing through the left greater sciatic foramen. Laparoscopic exploration showed a cyst full of dark fluid occupying the left obturator fossa and extending outside the pelvis. A novel combination of transgluteal laparoscopy was performed for complete resection of the cyst and decompression of the sciatic nerve. Postoperative pathology confirmed the diagnosis of endometriosis. Long-term follow-up observation showed persistent pain relief and lower limb function recovery in the patient.”
Brain
“We describe a case of cerebellar endometriosis in a 39-year-old woman who underwent posterior fossa decompression multiple times without establishing a correct diagnosis. Her neurologic status progressively worsened due to chronic hydrocephalus and brainstem compression by cysts. Late in the clinical course, histology from the cyst wall was taken that revealed endometriosis with clear cells and positive immunohistology for progesterone and estrogen receptors. Treatment with gestagens was started but did not improve the patient’s status. In patients with chronic recurring intracranial cysts and hydrocephalus, cerebral endometriosis should be considered.”
Heart (Cardiac):
“We reported a 28-years old woman who suffered from thoracic endometriosis syndrome accompanied by cardiac involvement. Also our patient is the third report of surgically documented thoracic endometriosis syndrome, involving right side pleura and pericardium.”