Keywords : scar endometriosis, episiotomy, cyclic spotting
A 36 year old woman belonging to high socioeconomic status came to the OPO on 3rd August, 1999 with a history of repeated vaginal discharge, itching over the vulva and spotting for the last five months. The spotting was associated with all the menstrual molimina. She was anxious thinking spotting to be a manifestation of some malignancy. She had undergone total hysterectomy in July 1998for symptomatic uterine fibroids. Considering her age ovaries were left behind. For her problems, she had undergone repeated gynecological examination by many gynecologists in the past but to no avail.
Her abdominal examination was normal. On examining the vagina, it was found to be full of white frothy discharge with fishy odor. After cleaning the vagina, its vault was found to be healthy with the granulation tissue. Bimanual examination d id not reveal any mass or thickening in the pelvis. She was assured and fully investigated. Her routine blood examination was normal. Serum HCC level was 0.8ID I ml (normakl0mIU Iml), CA-125 was 8 Ulml (normal 0-45 U/ml), USC and CT Scan of the pelvis were normal. Urine showed pus cells. She showed one old report of PAP smear of the vaginal vault which was found to be normal.
She was reassured that there was no malignancy and was given daily betadine vaginal wash along with teraconazole vaginal pressary and oral secnidazole, fluconazole and anxiolytic. After 14 days, she had no vaginal discharge and repeat urine examination was normal. Her PAP smear examination was repeated and was again found to be normal. For three months, she did not come for follow up.
In December1999 she came again with complaint of cyclical vaginal spotting. On thorough examination, no abnormality was detected but considering her history of cyclicalspotting she was put on danazole 200 mg thrice a day to be taken continuously and to come for regular follow up.She came in March 2000 with severe vaginal discharge and history of spotting since 20 days. She had stopped taking danazole on her own after 15days of starting due to side effects. She was again treated for vaginal discharge. On the fifth day of vaginal wash, a blue domed cyst of 3x3 mm was found in the posterior vaginal wall slightly to the right and 3.5 em above the introitus. She was asked regarding the history of episiotomy during delivery which she confirmed.She also gave history of curettage on the second day of her first delivery for retained pieces of placental membranes. Suspecting the cyst to be an ectopic endometrial tissue at the apex of episiotomy a diagnostic laparoscopy along with the excision of the cyst was done. Laparoscopy revealed healthy ovaries and vaginal vault. There was no endometriotic spot anywhere in the pelvis. A histopathological examination of the cyst showed endometrial glands in secretory phase along with squamous epithelium of the vaginal wall. After this, she was relieved of her spotting and anxiety.
This case is presented because of its rarity and the severe fear psychosis it caused to the patient for almost 18 months. All repeated vaginal examinations could not spot the endometriotic cyst in the past. We also could not detect the cyst during the first examination. Extra - pelvic endometrosis is rare (1%-2%)and may result from vascular and lymphatic dissemination of endometrial cells', Various sites can be vulva, vagina, cervix, appendix, rectum, colon, small intestine, lungs, pelvis, skin etc. In our case, endometriosis apparently was due to ectopic transplantation of endometrial cells at the episiotomy site in the vagina after curettage following the first delivery. For obvious reason she complained of cyclic spotting only after surgical menopause. The chance of implantation endometriosis significantly increases with postpartum curettage. Paull and Tedeschi' reported 15 instances of scar endometriosis in 2208 patients who underwent . curettage following delivery and none in 13,800who had no curettage following delivery. Scar endometriosis should be actively looked for in patients with vaginal spotting even after hysterectomy so as to avoid wmecessary mental harassment of the patient for fear of mal ignancy.
