Endosalpingosis as a cause of chronic pelvic pain

Susan A. Davies, MD, and Victoria M. Maclin, MD

Chicago, Illinois

Endosalpingosis, a condition characterized by ectopic oviduct epithelium, is diagnosed histologically by the appearance of benign ciliated and nonciliated columnar cells in an abnormal location. Endosalpingosis is typically without symptoms. Our unusual case report shows symptomatic endosalpingosis first seen with

chronic pelvic pain. Various aspects of this disease will also be discussed. (AM J OBSTET GYNECOL 1991 ;164:495-6.)

Key words: Endosalpingosis, pelvic pain, ectopic tubal epithelium

Endosalpingosis is a condition characterized by ec­topic oviduct epithelium.' Typically endosalpingosis is diagnosed histologically by the appearance of benign ciliated and nonciliated columnar cells, along with peg cells, in an abnormal location. ' Macroscopically this dis­ease is usually not detectable. When visually obvious, endosalpingosis can be seen as multiple, punctate (I to 2 mm), white to yellow, opaque or translucent, fluid­filled, cystic lesions that grossly impart a granular ap­pearance to the involved peritoneal area as exemplified by the following case report. 2 Rarely, larger cysts may be present.

Case report A 19-year-old white gravida 0 female was first seen

with pelvic pain. Her pain had progressed since men­arche from dysmenorrhea to occasional intermenstrual pain to virtually constant pain. She began menarche at age 14 years. Severe menorrhagia and dysmenorrhea resulted in her being placed on oral contraceptives soon after menarche; however, oral contraceptives were dis­continued by age 15 years because of depression. Ces­sation of oral contraceptives resulted in resumption of progressive dysmenorrhea.

Multiple medical opinions were sought for pain re­lief. In November 1988 she underwent diagnostic la­paroscopy. Biopsy specimens of the pelvic peritoneum revealed "a few ciliated polygonal-epithelial lined cysts with a focal underlying endometrial-type stroma con­sistent with endometriosis foci." Subsequently, she un­derwent 6 months of Danocrine therapy for suppres­sion of endometriosis. Dosage during the first 5 months was 800 mg per day. However, during the sixth month, because of persistent vaginal bleeding and despite hav-

From the Department of Obstetrics and Gynecology, Rush­Presbyterian-St. Luke's Medical Center. Received for publication May 10, 1990; revised September 6, 1990; accepted September 14, 1990. Reprint requests: Victoria M. Maclin, MD, Section of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Rush­Presbyterian-St. Luke's Medical Center, 1653 W. Congress Park­way, Chicago, IL 60611. 611 125746

ing achieved pain relief, her dose was increased to 1000 mg per day. Discontinuation of therapy was followed by rapid resumption of pelvic pain, leading to a second laparoscopy at another institution in May 1989. Pelvic inspection at that time revealed "miliary dissemination of minute particles and nodules between 0.5 mm and 2 mm in diameter." These biopsy specimens were his­tologically described as "atypical cysts, rule out rup­tured serous cystadenoma of ovary," despite normal appearance of the ovaries at the time of laparoscopy.

The patient was referred to Rush-Presbyterian­St. Luke's Medical Center, Section of Gynecologic On­cology, where slides from the previous biopsy speci­mens were reviewed and a diagnosis of endosalpingosis was made. She was referred in August 1989 to the Section of Reproductive Endocrinology for hormonal suppression with a gonadotropin-releasing hormone agonist. She reported a progressive decrease in pain during the previous month. A urinary ~-human cho­rionic gonadotropin test was performed (because of persistent amenorrhea during the 4 months since dis­continuation of Danocrine therapy) and was positive. Pelvic examination revealed a 7-week-size uterus and vaginal ultrasonography indicated a 7Y2-week intra­uterine pregnancy. In view of her pregnancy and de­creasing pelvic pain, no medication was prescribed.

Comment

Endosalpingosis was first described in 1930 by Samp­son.' His study of 100 cases of tubal stumps after tubal ligations led to the observation that sprouts of fallopian tube epithelium often invade the wall of the stump and may even extend beyond it after healing is complete.' Endosalpingosis is typically located in the visceral pelvic peritoneum covering the uterus, fallopian tubes, ova­ries, and cul-de-sac. Less frequent locations involve the pelvic parietal peritoneum, omentum, bladder and bowel serosa, periaortic area, and within the skin. 2 En­dosalpingosis is commonly associated with previous tubal surgery such as tubal sterilizations and salpin­gectomies and is also associated with chronic salpingi­tis.' Furthermore, it is usually a process without symp-

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toms, noted incidentally by a pathologist on a histologic specimen. It is of interest that symptomatic endosal­pingosis (unlike the condition without symptoms) is as­sociated with psammoma body formation. 2

The various hypotheses as to the cause of endosal­pingosis are: (1) transplantation, tubal mucosa is trans­planted to peritoneal surfaces, usually during surgery; (2) direct extension, tubal epithelium extends to the peritoneum as exhibited by adhesion formation; (3) reactive, salpingitis causes tubal epithelium to prolif­erate with repair being the goal and retrograde spill results; (4) coelomic metaplasia, coelomic peritoneum cells are multi potential and can differentiate into ovi­duct epithelium; and (5) lymphatic-vascular spread.2

It is important to rule out endosalpingosis when en­dometriosis is being considered because both have been reported in the same person. Endometriosis is histo­logically characterized by the presence of endometrial glands and stroma. Furthermore, endometriosis often has a hemorrhagic appearance as a result of this tissue's response to hormonal stimuli. Endosalpingosis, as stated previously, is histologically characterized by the appearance of benign ciliated and nonciliated columnar cells in an abnormal location. Endosalpingosis does not exhibit a hemorrhagic response to hormonal stimuli, which further helps in the differentiation of this con­dition from endometriosis. Also metastasis from ovar­ian papillary serous tumors must be differentiated from endosalpingosis inasmuch as both may have psam­moma bodies and endosalpingosis may form a papillary configuration as a result of irritation, trauma, or ma-

February 1991 Am J Obstet Gynecol

nipulation. Histologic features that support the diag­nosis of metastasis from an ovarian papillary serous tumor include the presence of an infiltrative pattern, a desmoplastic stromal response, the presence of only one cell type, and the absence of a basement membrane surrounding the glands! The latter morphologic fea­tures do not characterize benign endosalpingosis.

In summary, endosalpingosis is a benign disease that is diagnosed histologically by the presence of ectopic oviduct epithelium. Our patient exhibits several un­usual aspects of this process. First, the extent of the disease is evident macroscopically with the apparent miliary dissemination. Also, our patient is symptomatic, contrary to the usual presentation without symptoms. Although the cause of this disease remains unknown, it is likely that several of the proposed hypotheses may actually play a role. To date there is no known treatment protocol for endosalpingosis, but hormonal suppression regimens commonly used for endometri­osis may be of benefit in this special group of patients as exemplified by our case report.

REFERENCES

1. Onybeke W, Brescia R, Eng], Quagliarello ]. Symptomatic endosalpingosis in a postmenopausal woman. AM] OBSTET GYNECOL 1987; 156:924-6.

2. Blaustein A. Endosalpingiosis. In: Jurman R], ed. Blau­stein's pathology of the female genital tract. New York: Springer-Verlag, 1987;536-9.

3. Sampson ]A. Post salpingectomy endometriosis (endosal­pingiosis). AM] OBSTET GYNECOL 1930;20:443-80.