A Mother of Four With Menstruation Issues and Debilitating Pain

Linda A. Dultz, MD, MPH; Karina L. Vivar; Suzanne MacFarland; MaryAnn Hopkins, MD, MPhil


January 17, 2023

The estimated prevalence of endometriosis is 10% in the general population, and it is a leading cause of gynecologic-related hospitalization.[4,5] The true prevalence of endometriosis is most likely underestimated because the disease can be asymptomatic or manifest only minimal symptoms and can be difficult to diagnose without surgery.[2]

Several clinical features are commonly seen in patients with endometriosis, including age between 30 and 40 years, nulliparity, and involuntary infertility. They also may have dysmenorrhea, dyspareunia, and the classic symptom, pelvic pain.[2] Pain and infertility are the most common sequelae of this disease and can cause devastating effects on the physical, mental, and social well-being of affected women.[6]

Due to a lack of sufficient studies, the true prevalence of extrapelvic endometriosis remains unknown. Extrapelvic endometriosis has been reported in the gastrointestinal tract,[7] appendix,[8] inguinal canal,[9] liver,[10] lung,[11] umbilicus,[12] cesarean scar,[13] and rectus abdominus.[1] Cases have also been reported of abdominal wall endometriosis following needle introduction from amniocentesis.[14,15]

Blanco and colleagues[16] noted a 4% prevalence of abdominal wall endometriosis in a retrospective study of 297 patients with endometriosis. Common clinical symptoms for these cases of endometriosis included a palpable mass, dyspareunia, menorrhagia, and dysmenorrhea.

The initial workup of possible extrapelvic endometriosis should include a detailed history and physical examination, consideration of various imaging modalities (ultrasonography, MRI, CT scanning), and/or fine-needle aspiration (FNA).

FNA of an endometriotic mass demonstrates the tubular and spindle-shaped stromal cells seen in endometriosis. Endometrial glands with endometrial stroma can also be appreciated on hematoxylin-eosin stained specimens.[17] Imaging modalities used to help determine the extent of endometriotic masses for surgery include ultrasonography, CT scanning, and MRI. Classic endometriosis demonstrates low-level homogeneous internal echoes on ultrasonography and is found in 95% of cases.[18] CT scanning of these masses is nonspecific, with findings including simple to complex cystic structures and contrast enhancement due to vascularity and hemorrhagic components.[19] MRI is the most specific modality because it can detect hemorrhagic nodules containing degenerated blood product, with T2-weighted images showing progressive loss of signal in the dependent portion of the lesion as a result of accumulation of chronic blood products from cyclic bleeding.[20]


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