At the age of 30, the patient presents with a 2 year history of infertility. Her menses are still regular but she has 2-3 days of spotting before her menses are due. She also complains of pain with intercourse and pelvic pain. In reviewing the patient’s history, the gynecologist notes that over the past year the patient was repeatedly treated by her internist with antibiotics for recurrent microscopic hematuria.

What is the most likely diagnosis?What are the main theories regarding the

pathogenesis in this case?How would you evaluate and treat this

patient?

Theories

Retrograde menstruation (Sampson)Hematogenous or lymphatic spread (Halban)Coelomic metaplasia (Meyer/Novack)Iatrogenic disseminationImmunologic defects (Dmowski)Genetic predisposition

Symptoms

Asymptomatic DysmenorrhoeaMenorrhagia Lower abdominal

painInfertilityChronic pelvic painCyclical bleeding

Signs

P/A Cystic swelling Fixed Tender

P/S Bluish or blakish puckered spot

P/V Tender ,fixed, retroverted uterus B/L mass Palpable tender nodules in POD/utero-sacral

Differential diagnosis

PIDUterine myomaMetastatic deposit of malignant ovaryRectal malignancy

Prevention is better than cure

Avoid pelvic examination during / tubal patency test in premenstrual phase

Schedule surgery on genital tract in postmenstrual phase

Age Need for preserving reproductive functionSeverity of symptomsExtent of diseasesResponse to medical management Attitude of the patient towards her problem

Objective of treatment

To eradicate the lesionAvoid recurrence Alleviate the symptomsFacilitate the child bearing Lead a comfortable life

Management

Asymptomatic Expectant

Symptomatic Medical Minimal invasive surgery Surgery

Medical

NSAIDCOCProgestogensGnRH analogues Aromatase inhibitorsRU-486

Minimal invasive surgery

Destruction by cautery, laser vaporizationExcision of cystAdhesiolysisPresacral neurectomyLUNA

Surgery

Incision of cyst and removal of liningSalpingo-oophorectomyHysterectomy +/- BSOScar excision

Assessment

Discuss the C/F and management of pelvic endometriosis in a young nulliparus woman

A woman, P1L1 with dysmenorrhoea , menorrhagia and chronic pelvic pain. A tender mas is felt in right fornix . How will you investigate and manage the case ?

Short notes C/F and management of chocolate cyst of ovary

Reference

Shaw’s Text book of Gynaecology 16th edition