Painful catamenial vulvar lesions misleading gynecologist

Endometriosis usually presents as cyclical pain in the pelvis but may also present as painful cutaneous lesions. Many diseases may mimic hidradenitis suppurativa (HS) since HS, a chronic inflammatory painful skin disease, is a clinical diagnosis. A 32-year-old woman presented with painful lumps on her vulva and groin accompanied with bloody discharge during menstruation. She was followed up with preliminary diagnosis of endometriosis. Previous excision without definitive diagnosis resulted in temporary relief. She was prescribed oral contraceptive pills that alleviated her symptoms but quitted due to headache. Surgical excision was performed for definitive diagnosis and therapeutic relief. Pathology report revealed HS. She was prescribed oral doxycycline. She responded well to the therapy and has symptom-free for the last 2 years. She delivered one healthy girl via cesarian section 2 years after the treatment. Endometriosis and HS should be included in the differential diagnosis when women present with menstrual painful lesions around external genitalia for diagnosis and treatment.

Prevalence and determinants of ectopic pregnancy in Ethiopia: Systematic review and meta-analysis

Background: Ectopic pregnancy is a life-threatening obstetric emergency, and is a major health problem for women of fertile age. Therefore, the aim of this systematic review and meta-analysis was to estimate the prevalence, determinant factors, and outcomes of ectopic pregnancy among fertile age women in Ethiopia. Method: International databases (MEDLINE/Pub Med, Hinari, Scopus, Google scholar, African journals, and literatures were searched and nine eligible cross sectional and two case control studies were included in this systematic review and meta-analysis. Eggers test and funnel plot were computed to check publication bias across the studies. Publication bias was computed using a funnel plot and eggers test. Heterogeneity of the studies was checked using Cochrane Q-test and I2 statistic. Results: The pooled prevalence of ectopic pregnancy in Ethiopia was 3.61% (95%CI: 2.24–4.98, I2 = 89.2.0%, p < 0.001). Having cesarean section scar (AOR = 7.44, 95%CI: 5.48–10.09), single marital status (AOR = 5.71, 95%CI: 4.76–6.85), history of sexually transmitted infection (AOR = 4.68, 95%CI: 3.04–7.19), history of abortion (AOR = 3.89, 95%CI: 3.35–4.52), history of ectopic pregnancy (AOR = 5.74, 95%CI: 3.81–8.65), and emergency contraceptive use (AOR = 8.72, 95%CI: 2.90–26.20) were the determinant factors for the occurrence of ectopic pregnancy. Conclusion: This systematic review and meta-analysis showed that the prevalence of ectopic pregnancy was high in Ethiopia. Thus, educating women to limit the number of sexual partners, smoking cessation, using a condom during sex helps prevent sexually transmitted infections and the risk of pelvic inflammatory disease is crucial.

Retinoic acid action is altered within endometrium of baboons affected with endometriosis

Objective: Using a baboon model, we determined the changing expression of Retinoic Acid (RA) target genes during the menstrual cycle and during disease progression. This change could explain the cellular response and changes characteristic of endometriosis. In previous studies, we established that endometriosis affects the CRABP2:FABP5 ratio in an in vitro environment, shifting toward apoptosis and differentiation with higher CRABP2, and anti-apoptosis with higher levels of FABP5. Intervention(s): Endometriosis was induced in female baboons with intraperitoneal inoculation of menstrual endometrium ( n = 2–4). Tissue was harvested via endometrectomy during different stages of the menstrual cycle as well at 3, 6, and 12 month timepoints after inoculation with endometriosis. Main outcome measure(s): Real time PCR was used to quantify STRA6 (a gene responsible for retinol uptake), CRABP2 (a gene necessary for apoptotic and anti-apoptotic estrogenic RA effects), and FABP5 (a gene that mediates the anti-apoptotic actions of RA). Results: STRA6 and CRABP2 expression were highest in the proliferative phase and lowest in the late secretory phase. FABP5 expression remained stable throughout the 12 months following the induction of the disease, whereas STRA6 and CRABP2 continued to decrease during the same period. Conclusions: Our study confirms that a shift in the CRABP2:FABP5 ratio has similar in vivo effects as it does in vitro: changing RA expression with disease induction and progression. As CRABP2 may be important in determining cell fate in the endometrium, gene expression changes could contribute to the anti-apoptotic behavior of affected cells. As expression changes more during progression, earlier rather than later treatment becomes more critical in reducing the rate of disease progression.

Body mass index and vitamin D as risk factors for the development of uterine leiomyomas in Mexican women

Objective: The objective of the present study was to determine if body mass index and vitamin D levels are risk factors for the development of uterine leiomyomas in Mexican women. Methods: A cross-sectional study was designed. Inclusion criteria were women between 20 and 55 years with a suspect of uterine leiomyomas. Transvaginal ultrasonography was made to confirm the diagnosis and clinical variables were collected. Vitamin D levels were measured in serum by chemiluminescence immunoassay. Binary linear regression analysis was conducted to assess the predictors of uterine leiomyomas. Results: A total of 106 patients were evaluated, the mean age was 41.4 ± 8.0 years. The serum levels of vitamin D were insufficient in 94 (88.7%) and 82 (77.3%) has overweight or obesity. However, only 50 (47.2%) of participants have a diagnostic of uterine leiomyomas. BMI not increased the probability of having insufficient levels of vitamin D or uterine leiomyomas. Only, age (> 45 years) and levels of vitamin D (<30 ng/mL) were predictors of uterine leiomyomas (OR 10.345, 95% CI 2.737–39.095; p = 0.001; and OR 2.26, 95% CI 1.011–5.073; p = 0.014), respectively. Conclusions: Insufficient levels of vitamin D are common in Mexican women. Age and hypovitaminosis D are possible risk factors in the development of uterine leiomyomas in Mexican women.

Patient acceptability and quality of self-administered intravaginal gel for pelvic MRI

Background: MRI of the pelvis can be limited for infiltrating lesions or those of same signal intensity as surrounding structures. Vaginal distension using aqueous gel counters this by defining the fornices, cervix and anterior rectal wall. This increases the accuracy of diagnosis and staging of various pelvic pathology, however, there is currently neither a universally accepted protocol for using gel nor focus on patient self-administration. Aims: To improve patient expectations regarding pelvic MRI with intravaginal gel, as well as the service we provide should they prefer self-administration and this produces vaginal distension of radiological quality equivalent to doctor-administration. Methods: Illustrated information explaining the benefits of gel and the technique of self-administration was sent to patients scheduled for pelvic MRI between March 2020 and April 2021 at our study centre. This included a questionnaire to assess understanding and preference for self-administration. Vaginal distension achieved on imaging was analysed using TeraRecon and compared between self and doctor-administered cases. Results: 38 of 45 patients opted for self-administration of gel. Those who identified as White British were more likely to self-administer. There was comparable quality of vaginal distension between self and doctor administered cases, with no significant difference between orthogonal measurements and retained gel volume. Conclusion: Self-administration of intravaginal gel for pelvic MRI is acceptable to patients and frees a doctor of this duty. It is a well tolerated technique which produces high quality vaginal distention on imaging. We recommend wider use of intravaginal and even rectal gel in the investigation of complex endometriosis and pelvic tumours.

Double trouble: pelvic pain associated with a dual presentation of endometriosis and granulomatous peritonitis

A 34-year-old patient presented to our office with chronic pelvic pain. Prior laparoscopic surgery revealed endometriotic appearing lesions which were ablated. The patient opted for another surgery to diagnose and treat potential leftover endometriosis. Laparoscopy revealed the presence of endometriotic appearing lesions, but pathology revealed two different histological diagnosis: endometriosis and granulomas, even in areas where no endometriosis was encountered. In any granulomatous presentation, exposure to mycobacteria must be ruled out. Without excision of abnormal appearing lesions seen on laparoscopy, endometriosis can not be confirmed and other potential causes of pain cannot be excluded.

Intra- and inter-observer reproducibility of r-ASRM endometriosis classification system and its components, using edited videotaped laparoscopic procedures

Several classification systems have been proposed for endometriosis but the search for the ideal system is ongoing. While the most commonly used system has historically been r-ASRM, this system is not fit for purpose, particularly for deep endometriosis. In order to explore strategies to devise a new system and learn from problems with the existing ones, this study was designed to assess the reproducibility of each component in r-ASRM and its total score using videotaped laparoscopic procedures. Two surgeons independently scored 64 edited videos of laparoscopic endometriosis procedure, twice. Using the Kappa statistic, the agreement of the scores given was analyzed. r-ASRM showed a moderate inter-observer agreement (ƙ = 0.503) and good intra-observer agreement (ƙ = 0.774 and 0.682 for scorer 1 and 2 respectively) for overall disease staging. The agreement for each component of the system, however, was highly variable. The least agreement was observed for the peritoneum with ƙ = 0.157 and ƙ = 0.362 respectively for inter-observer and intra-observer. The lowest intra-observer agreement was seen for cul-de-sac for scorer 2 (ƙ = 0.382). Whilst the overall rASRM shows acceptable agreement between two scorers, this agreement seems to be the product of inconsistent scoring for each component.

Surgical lysis of nerve entrapment caused by retroperitoneal fibrosis/adhesions; two case reports and a literature review

Introduction: Retroperitoneal fibrosis (adhesions) in the pelvic area is rare and not well known in gynecology. However, their presence can cause compression neuropathy leading to severe pain symptoms involving the lower extremities. A neuropelveological approach can be applied in dealing with such cases in diagnosis and management. Objective: To demonstrate neurolysis of sacral nerves in patients with retroperitoneal fibrosis (adhesions). Case presentations: Case 1: A 43-year-old gravidity 1 parity 1 female patient with known endometriosis presented with dysmenorrhea, dyspareunia, and left-sided sciatica. Gynecological examination revealed a rectovaginal nodule and full obliteration of pouch of Douglas. Robot-assisted laparoscopic sacral neurolysis and dissection of pouch of Douglas with rectal nodule shaving was performed. The patient was symptom free 6 months postoperatively. Case 2: A 49 years old gravidity 2 parity 2 female patient presented with severe pain on the left groin and leg, dysuria, and constipation, which required frequent manual evacuation of the feces. The begin of her symptoms coincided with a previous laparoscopic total hysterectomy, where she experienced postsurgical hemorrhage. Laparoscopic sacral neurolysis with adhesiolysis was performed. The patient was symptom free 6 months postoperatively. Conclusion: Pelvic retroperitoneal fibrosis (adhesions) are rarely encountered in gynecology. However, they should be included in differential diagnosis in patients presenting with pelvic pain accompanied by lower extremity pain, urinary, and/or bowel symptoms. Since presurgical diagnosis of fibrosis (adhesions) is hard with visualization techniques such as transvaginal ultrasound or magnetic resonance imaging, a thorough neuropelveological examination can be helpful in such cases.

Challenges in chronic pelvic pain: Diffuse uterine capillary haemangioma simulating a clinical picture of adenomyosis

Introduction: Adenomyosis is a heterogeneous condition of difficult diagnosis that stands out in our patients for causing abundant menstrual bleeding, dyspareunia and dysmenorrhoea. However, in chronic pelvic pain units it is important to consider other conditions of similar symptomatologies, such as vascular malformations. These include capillary haemangiomas which, although rare in the reproductive tract, can produce serious symptoms. Case description: We present the case of a 31-year-old woman under observation by the chronic pelvic pain unit for dysmenorrhoea and dyspareunia since menarche. Ultrasound and magnetic resonance findings were compatible with adenomyosis. The patient showed no improvement with hormonal treatment. Upon failure of the medical treatment and taking into account the patient’s lack of gestational desire, a laparoscopic hysterectomy was performed. The pathological report revealed a diffuse capillary haemangioma as the cause of the symptoms. Given the completely curative nature of surgery for this type of condition, the patient was discharged from our unit. Conclusion: The preoperative diagnosis of adenomyosis is still a challenge and units specializing in chronic pelvic pain must consider all possible diagnostic options so as not to overlook rarer conditions such as vascular malformations.

Ultrasound features of polypoid endometriosis: a case report and a short review of Literature

Introduction: Polypoid endometriosis is a rare variant of endometriosis characterized by histological features resembling an endometrial polyp. Lesions frequently affect the ovaries presenting as adnexal masses which may mimic malignancy, with an extremely complex differential diagnosis due to the poor evidence reported in Literature. Case description: In this report, we describe the case of a 43 years old woman referred to pelvic transvaginal ultrasound examination for recurrent abdominal pain, in whom sonography revealed a pelvic mass with features highly suspicious for ovarian carcinoma. Surgical removal allowed histopathological diagnosis of polypoid endometriosis, with no signs of malignancy. At ultrasound examination, the lesion appeared as a multilocular-solid mass, with low-level echogenicity of cystic content, multiple papillary projections, and solid areas with high vascularization and apparent infiltration of the uterus. At retrospective review of the sonographic images after pathological examination, some features mirroring the histological architecture of polypoid endometriosis could be identified in the solid components of the mass: these included the hyperechoic appearance, the rounded outline of the intracystic projections, and the vascularization pattern with a single central vessel with branching. Conclusions: To date, this is the first work providing a detailed ultrasonographic description of polypoid endometriosis using shared terms and definitions and relating these findings with available evidence about radiologic and histopathologic features. The report shows how this condition could strongly mimick ovarian malignancy, though several sonographic features can be identified reflecting the histopathological patterns of those lesions.