Keywords:

  • 35 yo
  • nulligravida woman
  • cyclic debilitating pelvic pain realting to menses
    • 3 year history
  • failure to concerive & dyspareunia
    • 2 year history
  • menstrual cycles regular but heavy
  • No history of STD
  • Bimanual examination
    • normal sized immobile
    • retroverted uterus
    • fixed left adnexal mass
      • tenderness on palpation
  • Ultrasound
    • 8×6 cyst in left ovary
  • Laparoscopy performed
    • left ovary enlarged
    • adherent to fallopian tube & broad ligament
    • ill defined
    • dark brown cystic areas in ovary, posterior wall of uterus & pouch of Douglas

Hypothesis

  • Endometriosis
  • Adenomyosis
  • Fibroids
  • PID
  • Vaginismus
  • Vaginitis

Extra learning issues:

Dyspareunia

Painful sexual intercourse that is not caused exclusively by lubrication/vaginismus (spasm).

Pathogenesis of endometriosis (ovary)

  • Retrograde menstruation
    • Endometrial fragments transported through fallopian tube
  • Metaplasia of coelomic epithelium of the mullerian duct
  • Vascular/lymphatic spread to other sites

Ectopic endometrium bleeds during menstrual cycle because it responds to ovarian the same way as the uterine endometrium. The products of this metabolic activity causes release of cytokines & prostaglandins causing an altered inflammatory response. This causes fibrosis and adhesion of tubes, ovaries and obliterates the pouch of Douglas, resulting in infertility and pelvic pain.

The uterus is retroverted due to these adhesions. Besides that the cytokines will also kill the sperms passing through as well as the gamets.

Laparoscopy

  • Operation performed in the abdomen or pelvis where a small incision with the aid of a camera used to inspect and diagnose a condition or to perform a surgery.
  • It can be used to inspect the outer surface of the uterus, ovaries and fallopian tube as well.

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