The patient is a 30-year-old woman presenting with a 2-year history of infertility, regular menstruation with premenstrual spotting, and pelvic pain with intercourse. Her history notes repeated treatment for microscopic hematuria. The most likely diagnosis is endometriosis. Main theories for pathogenesis include retrograde menstruation and hematogenous or lymphatic spread. Evaluation and treatment would involve examining the patient and potentially treating with medications, minimal invasive surgeries such as cyst destruction, or more invasive surgeries such as cyst excision or hysterectomy depending on symptoms, extent of disease, and patient's goals.

1.  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.

2.  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?

4. Theories
 Retrograde menstruation (Sampson)
 Hematogenous or lymphatic spread (Halban)
 Coelomic metaplasia (Meyer/Novack)
 Iatrogenic dissemination
 Immunologic defects (Dmowski)
 Genetic predisposition

5. Symptoms
 Asymptomatic
 Dysmenorrhoea
 Menorrhagia
 Lower abdominal pain
 Infertility
 Chronic pelvic pain
 Cyclical bleeding

6. 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

7. Differential diagnosis
 PID
 Uterine myoma
 Metastatic deposit of malignant ovary
 Rectal malignancy

12. Prevention is better than cure
 Avoid pelvic examination
during / tubal patency
test in premenstrual
phase
 Schedule surgery on
genital tract in
postmenstrual phase

13.  Age
 Need for preserving reproductive function
 Severity of symptoms
 Extent of diseases
 Response to medical management
 Attitude of the patient towards her problem

14. Objective of treatment
 To eradicate the lesion
 Avoid recurrence
 Alleviate the symptoms
 Facilitate the child bearing
 Lead a comfortable life

15. Management
 Asymptomatic
 Expectant
 Symptomatic
 Medical
 Minimal invasive surgery
 Surgery

16. Medical
 NSAID
 COC
 Progestogens
 GnRH analogues
 Aromatase inhibitors
 RU-486

17. Minimal invasive surgery
 Destruction by cautery, laser vaporization
 Excision of cyst
 Adhesiolysis
 Presacral neurectomy
 LUNA

18. Surgery
 Incision of cyst and removal of lining
 Salpingo-oophorectomy
 Hysterectomy +/- BSO
 Scar excision

19. 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

20. Reference
 Shaw’s Text book of Gynaecology 16th edition