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Uncommon endometriosis

Dr.Shobhana Mohandas. MD.DGO.FICOG.

Chief Gynaecologist, Sun Medical Centre, Unit of Trichur Heart Hospital, Thrissur



Endometriosis is a disease where endometrium is placed outside the uterus, usually in the pelvis. However, it can be found in remote places outside the pelvis, and the diagnosis of endometriosis may elude the treating physician, unless the cyclical nature of the illness alerts the physician of the possibility of extrapelvic endometriosis.  Although, endometriotic lesions get activated cyclically, in some case reports, endometriotic lesions have known to produce symptoms in the intermenstrual period also, giving rise to a confusing clinical picture.  Quite often, the diagnosis is made incidentally on histology after surgery.  Since the symptoms are intermittent, it is also difficult to convince the patient of the need for surgery. 

. Rare extrapelvic sites are the pleura, lungs, breasts, extremities, abdominal scars,  the perineal region, particularly in episiotomy scars, gallbladder, central nervous system, extremities, perineum, and the abdominal wall. It has presented in inguinal and umbilical hernias. Endometrial tissue has also been identified in numerous surgical or procedural scars,including Cesarean section, laparoscopic trocar tract,a mniocentesis needle tract, and perineal episiotomy incisions. Beside the unusual locations of endometriotic lesions, the activation of endometriosis in a non estrogenic milieu can also be considered uncommon.  For example, endometriosis is normally quiescent in menopause and pregnancy, but there are rare case reports of these lesions having got activated during these periods, viz: menopause and pregnancy. 

Cutaneous endometriosis

Endometriosis is known to occur at various sites on the skin.  The lesions may cause cyclical pain, but sometimes they cause constant pain.  They generally present to the general surgeon, who excises thelesion, and a diagnosis of endometriosis is made on histopathology.

Endometriosis in Abdominal wall:

Endometriotic lesions have been found in the abdominal wall, both in patients who have undergone previous surgery on the uterus, and also in patients who have not had any surgery on the uterus; 

Various theories of abdominal wall endometriosis have been put forward.  The transport theory states that endometrial cells may be transported to distant locations after retrograde regurgitation through the fallopian tubes, vascular/lymphatic spread, or direct implantation through surgical scars, where they proliferate to form endometriomas1,. This may follow surgery on the uterus, like caesarian section, after which the endometrium is transported to the abdominal wall.    The metaplasia theory suggests that primitive pleuropotential mesenchymal cells undergo specialized differentiation metaplasia to form endometrial implants.  Whatever the origin,the lesions respond to estrogenic stimulation.

 The pathological characteristic of abdominal incision endometriosis appears as periodic haemorrhage of the ectopic endometrium and fibrosis of the focus2. The focus often involves the abdominal rectus and its sheath. The superficial focus even breaks through skin and can be observed as hemorrhage during menses.  On histopathology,the incision of focus looks grey or slightly yellowish; the microstructure is composed of endometrium, endometrial gland or endometrial gland-like structure with bleeding.

  In a majority of cases, it follows surgery on the uterus. The commonest surgery prior to scar endometriosis is caesarian section. Surgical scar endometriosis following

cesarean section has an incidence of 0.03%–0.4%17.Abdominal endometriosis has also known to follow tubal ligation,hysterectomy,ovarian cystectomy and diagnostic laparoscopy,(even at trocar sites53). 

Usually it presents in women over 30 years of age, although it can occur much earlier.  The onset of symptoms may vary, anywhere between 6 months to 10 years, but commonly it occurs a year after surgery1,2.   When the symptoms occur many years after original surgery, the history of previous surgery may be overlooked by the clinician, leading to difficulties in diagnosis. The patient usually presents with a swelling in the abdominal wall, which increases in size or becomes more painful at the time of menstruation. Rarely there may be any associated pain.  The lesion may even bleed during menstruation. Umbilical endometrioma has been described in patients without any history of surgery and without any evidence of pelvic endometriosis,the first description being in 1886. Usually, this type of endometriosis is associated with pelvic pain and dysmenorrhea, even though silent umbilical endometrioma has been described38.   


Examination in cases of abdominal endometrioma may reveal small lumps,in varying sizes, sometimes even as small as 1cm or 2 cm. In the literature, the mean size of masses has been 3.1 (range 1.5–4.8) cm17.  The differential diagnosis of the swelling could include hernias, suture granulomas, abscesses, malignant tumors, neuromas, and hematomas2. Imaging studies are not absolutely essential in diagnosis.  However, Ultrasound can help verify the depth of extension and the consistency of the lesion. CT scan can show extent of the lesion and whether it is acute or chronic.  Magnetic resonance imaging (MRI) has also been used in evaluation of endometriomas. Tl-weighted images may show a bright signal if acute hemorrhage is present, and T2-weighted images will show low signal intensity if bleeding is of a chronic nature1. Fine needle aspiration cytology (FNAC) may be used to rule out malignancy.


 Medical treatment has not been known to be fully successful in curing the disease.  Treatment is by wide surgical excision of the mass as there is a slight risk of development of malignancy2. If surgery involves removal of fascia,a mesh may need to be placed to prevent hernias.

Role of a gynecologist:

 Primary excision of the nodule may be done by the gynaecologist.  However, sometimes the gynaecologist may be called in only after the diagnosis of endometriosis has been made on histopathology.  One has to decide whether a laparoscopy has to be done to rule out pelvic endometriosis.  It has to be remembered that cutaneous endometiosis may be assossiated with  pelvic endometriosis in 20±46% of cases.51 If the diagnosis of endometriosis is made preoperatively, it may be prudent to combine the  excision procedure with an exploratory laparotomy or laparoscopy to rule out other foci of endometriosis.   The patient should be informed of the high rate of recurrence of this disorder. Follow-up should be arranged for those patients who present multiple recurrences, in order to avoid any chance of malignant transformation36. Pre-operative administration of GnRh analogues may reduce the size in selected cases, where there seems to be a need for reducing the size before surgery. 

Prevention of scar endometriosis could probably be attempted by conscious avoidance of not allowing instruments and swabs which have touched the endometrium at the time of caesarian section or hysterotomy from coming in contact with the subcutaneous tissues or skin.  Thorough sucking out and washing of endometriomas before ovarian cystectomy in chocolate cysts could also be useful in avoiding endometrial tissues from reaching the abdominal wall.  Washing the abdominal wound with saline, before closure, in laparotomy could be useful.


Perineal Endometriosis:

Perineal endometriosis may be caused by migration of endometrial tissue through the fallopian tubes into the pelvis or down the vagina into an episiotomy scar, after a vaginal delivery, manual uterine exploration, or postpartum curettage. It may also be caused by a metaplasia of müllerian duct remnants which develop into endometriotic tissue secondary to cyclical ovarian stimulation.   Depressed cell mediated immunity may favour the implantation of endometrial tissue at ectopic sites.


Patients with perineal endometriosis usually present with a tender perineal nodule which lies in relation to an episiotomy scar causing cyclic pain.   Episiotomy site endometriomas may also mimic anal abscess, and the diagnosis can be thought of, when, instead of pus, the swelling drains dark coloured chocolate material14. Endometriosis has been reported in the anal sphincter, the patient presenting with history of fluctuating pain in the right anterior perianal region without any apparent swelling anywhere.  An endosonogram of the anal canal detected the lesion in the external anal sphincter29


 Perineal endometriosis is best treated by wide excision.  When the patient presents with a fluctuating lesion near the perineum, sometimes simple drainage may be done thinking of it to be an abscess.  However, simple drainage will inadvertently lead to recurrence.  Use of  Goserlin acetate for 3 months preoperatively has been described by  Kang et al in a 5cm endometriotic lesion in the perineum, which developed over 4 years after her last vaginal delivery, involving an episiotomy14.  Since perinal endometriosis may involve vital structures like rectum or anal sphincter, in large lesions, it may be prudent to reduce the size of the lesion before attempting excision. 


Vaginal vault endometriosis:

Endometriosis of the vaginal vault can appear as reddish lesions, which may bleed.  When plain estrogen is given to women with history of hysterectomy with bilateral oophorectomy, these lesions could bleed, sometimes profusely.  Stopping estrogenic stimulus could be enough to stop  the bleeding in such cases. 

Vaginal vault endometriosis has been described in patients after laparoscopic hysterectomy where a lot of morcellation had been used.  In such cases, surgical resection of the lesion may be necessary. 


Endometriosis of the Urinary Tract

Patients with urinary symptoms may primarily visit the gynaecologist, who should therefore be alert to possibility of endometriosis of the urinary tract, which occurs in 1-2% of the cases. 

Bladder Endometriosis:

The majority (84–90 per cent) of urinary tract endometriosis affect the bladder and the lesion is generally located behind the trigone or on the bladder dome. There are two forms of bladder endometriosis: isolated or associated with peritoneal endometriosis. The former seems to appear after iatrogenic dissemination of endometrial cells after surgery (caesarean section, hysterectomy or dilatation and curettage). In the latter, the bladder lesion is a manifestation a generalized pelvic disease.  Diagnosis:    

Patients may present with cyclical dysuria ,abdominal pain or increased urinary frequency with or without haematuria.  There is usually a delay in diagnosis of the disease, and the patient may undergo many different types of therapy like  repeated antibiotics, anticholoinergic drugs or even benzodiazepines.  Clinical symptoms generally peak 1 week before and after menstruation, and in more than 70 per cent of the cases they are identical to those of interstitial cystitis.

 Ultrasonography may show a mass in front of the vagina. A cleavage plane may be found between the lesion and the detrusor muscle.   Cystoscopy may show a bulge into the bladder wall or a bluish lesion .  Sometimes, the  bluish lesions may not be visible,leaading to false negative cystoscopy.  The lesion may not be visible laparoscopically, although laparoscopy can rule out concomitant pelvic endometriosis.


Bladder endometriosis is amenable to medical therapies, but the symptoms usually recur on stopping treatment.  However, response to hormonal therapy and recurrence on stopping treatment may help clinch the diagnosis in difficult to diagnose cases.  In post menopausal bladder endometriosis, long lasting cure could be expected, as the oestrogenic milieu is no longer there near the lesion.

   Surgical treatment should involve  total excision of disease, which may mean a partial cystectomy. The cystocopic route is generally contraindicated because of the risk of perforation or short-term recurrence due to incomplete excision. Laparotomy tends to be the treatment of choice, especially in cases of multifocal lesions.  Laparoscopy has a disadvantage that it will not allow palpation of the  lesions. 

Ureteric endometriosis:

Ureteric endometriosis as sole manifestation of the disease was first described in the literature in 195648. It is rare and may result in a high rate of renal loss before it is recognized.  The ureter is most commonly affected in the distal third.  It may be extrinsic in 70-80% of cases, causing progressive stenosis of the ureter.  The intrinsic form subverts the muscular layer or the ureteral mucosa, always also involving the adventitial coat and periureteral tissues.


Ureteric endometriosis may present with hydronephrosis, caused by back pressure to the kidneys or anuria if there is bilateral involvement.  USG is useful to look for hydronephrosis.  Intra Venous Urography can detect status of ureteric function. 


Management is by ureterolysis with excision of endometrial tissue and laparoscopic partial resection of the ureter with uretero-ureterostomy or neo-cystostomy.    Medical therapy is generally not successful.


Intestinal tract

Endometriosis affects the intestinal tract in 3% to 37% of all patients with pelvic endometriosis.  Common sites include the sigmoid colon and rectum  (85%), small bowel (7%), caecum (3.6%) and appendix (3%).  The incidence is highest in the sigmoid and rectum, because they are the  most  dependent portions of the bowel, as well as being directly adjacent to the gynecologic organs.22   The incidence of mucosal and submucosal involvement by intestinal endometriosis is estimated to be only 30% and 66%, respectively, making preoperative diagnosis of  intestinal endometriosis a difficult proposition.


Ileal Endometriosis:   

The majority of small bowel involvement occurs in the distal ileum, especially the last l0cm ofthe terminal ileum16. Patients may remain asymptomatic.  They may also present with chronic symptoms, or symptoms of acute intestinal obstruction.  Episodes of obstructive symptoms will occur close to the menstrual period.  The cause of the bowel obstruction could be either endometrial tissue causing an intusception or volvulus, or, a fibrotic stricture in the bowel wall. The latter is due to release of fibrogenic ferrous material from degraded blood, occurring at each menstruation from ectopic endometrial tissue.  The white cell count may sometimes be elevated, making diagnosis difficult. When they present with obstruction or intussusseption, generally, resection anastomosis becomes necessary and the diagnosis is then made on the histopathology of the specimen.  

Appendicular Endometriosis:

Sampson first described endometriosis involving the appendix, in 1921, with the documented  frequency of appendiceal involvement in patients with endometriosis ranging from less than 1 to 5.3%2 and the frequency of endometriosis of appendicectomy specimens ranging from 0.05 to 0.80%4  .  The appendix is estimated to be involved by microscopic endometriosis in >10%

of patients with ovarian endometriomas . 

Diagnosis; Patients with isolated appendicular endometriosis may remain asymptomatic or present with acute abdominal pain, a palpable mass in the lower abdomen or chronic recurrent bouts of abdominal pain associated with vomiting and diarrhoea..  It is generally asymptomatic, and found as an incidental finding at laparotomy.  Endometriosis of the appendix may also present as acute appendicitis, intestinal obstruction resulting from intussusception of the appendix or lower gastrointestinal bleeding. 

Colonic Endometriosis:   

Patients may present with rectal bleeding with evidence of mass in the intestine, on CT scan,at the site of endometriosis;.  Perforation of the sigmoid colon due to endometriosis has been reported in a 28 year old woman during pregnancy46.  Diagnosis is usually made on the histopathology of the resected mass. 

Rectal Endometriosis:

Rectal endometriois can present with cyclical rectal bleeding, diarrhea, with or without abdominal pain.  Biopsy of the endometriotic area may not always yield a diagnosis because the endometrial tissue rarely infiltrates the mucosa. Medical treatment could be tried, but if it fails surgical treatment  is by resection anastomosis of the rectum. This can be done laparoscopically or by laparotomy.  Transanal endoscopic microsurgery has been described for indicated for small lesions (<1 cm) 34.






Thoracic endometriosis


Endometriosis is known to affect the lung in it’s parenchyma, as well as in the pleura54.  Thus in any patient coming with cyclic respiratory symptoms like cough, dyspnea etc, the possibility of lung endometriosis should be thought of , 

Both pleural and parenchymal lesions are found more often on the right side than the left.

Most patients with pleural endometriosis also have pelvic endometriosis. In contrast, parenchymal endometriosis usually occurs in women without co-existing pelvic disease and is believed to arise from embolism of endometrial tissue from the uterus to the lungs via the pulmonary arteries. Parenchymal endometriosis occurs more frequently in the lower lobes, where blood perfusion is greatest. 

Pleural Endometriosis:

Catamenial pneumothorax is the commonest manifestation of pleural endometriosis. Catamenial pneumothorax is recurrent pneumothorax that occurs within 72 hours of menstruation.   Three distinct mechanisms have been proposed for the assossiation of spontaneous pneumothorax and the menstrual period  based on metastatic, hormonal, and anatomical models7,6,.

Metastatic model:  The metastatic model suggests migration of endometrial tissue via the peritoneal cavity through transdiaphragmatic lymphatic/ hematogenous  routes  or through diaphragmatic fenestrations into the pleural space. Because these congenital diaphragmatic channels or fenestrations are more common in the right hemidiaphragm, manifestations of thoracic endometriosis occur predominantly on the right side of the chest. Alternatively, it is postulated that endometrial tissue may be deposited in the chest cavity during embryonal development. Monthly shedding of endometrial tissue is believed to result in pleural irritation that causes chest pain and pulmonary air leaks, resulting in pneumothorax. This theory is supported by the identification of endometrial deposits in the pleural space, present in 13% to 62.5% of these patients. 

Hormonal model: The hormonal hypothesis proposed by Rossi and Goplerud  in 1974 suggests that high serum levels of prostaglandin F2 at ovulation may lead to vasospasm and associated ischemia in the lungs. They speculated that this tissue injury, combined with prostaglandin-induced bronchospasm, may result in alveolar rupture and pneumothorax. However, since Non Steroidal Anti Inflammatory agents are not effective in this condition, this theory has fallen out of favour. 

Anatomic model:  The anatomical model is based on the influx of air into the pleural space from the peritoneal cavity via diaphragmatic fenestrations. This model postulates that during menstruation, there is a  loss of the cervical mucus plug .  This allows, air to enter  into the peritoneal cavity via patent fallopian tube(s) and subsequently into the pleural space via communication through the diaphragm.  

Parenchymal endometriosis : Vessels in the lung filter blood for exchange of gases.  Park33 postulated that during this process, endometrium which may have travelled in the blood may be trapped by the lung vasculaure.

Endometium may have reached the blood following a curettage or caesarean section33.

Clinical presentations and management  of Thoracic endometriosis:

 Thoracic endometriosis syndrome could present as Catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and lung nodules.

Catamenial pneumothorax: It is a very rare disease affecting women between 30 and 40 years of age.  The most common symptoms of catamenial pneumothorax are right sided pleuritic pain and dyspnea.  Pneumothorax is diagnosed by noting appropriate physical findings (i.e., diminished/absent breath sounds on the affected side) and documenting the presence of pneumothorax on chest radiograph.    However, pneumothorax may not recur at every menstrual cycle, and is not always associated with pelvic endometriosis.  Additional investigations like  CT or MRI and may show diaphragmatic or pleural thickening in affected lung areas.   Endometriomas appear as hypodense nodules on CT scan if they are larger than 1 cm, whereas a homogeneous hypersignal is seen on MRI.

There are currently two modalities to treat catamenial pneumothorax—hormonal and surgical.

Hormonal treatment modalities include the use of OC pills, danazol, progestational agents, and gonadotropin-releasing hormone (GnRH) analogs. The optimal length of treatment has not been clearly defined but is

based on successful suppression of recurrence of the pneumothorax. In most studies, treatment is

Implemented for a minimum of 6 months.  However, hormonal therapy alone, is not sufficient to control symptoms in a majority of cases.

Surgical options to treat catamenial penumothorax include, Video Assisted Thoracoscopic Surgery (VATS) with inspection of diaphragmatic surfaces for defects, or by thoracotomy. Nodular blebs in the pleura are excised endoscopically or by thoracotomy with Pleuodesis and pleural abration,and sealing of diaphragmatic defects .  Catamenial haemothorax: Chemical or or  well-defined opacities several centimeters in size, nodular lesions, thin-walled cavities, cystic changes, and bullous formation54. All of these lesions may vary in size during the menstrual cycle and may disappear after the menses. Pulmonary nodules were observed more often in older women. With increasing age, hormonal support for the viable endometrial tissue decreases and endometrial tissue with surrounding fibrotic tissue may occur as a lung mass or infiltrate on a chest radiograph.


Role of a gynaecologist:  A gynaecologist should be alert to the possibility of pleural or parenchymal lung endometriosis in patients with cyclical respiratory symptoms.  She/He should resort to investigative modalities like chest radiograph or CT scan of the chest even though the symptoms may appear trivial initially, as they appear only cyclically.  Referral to thoracic surgeons may be done after diagnosis.   If a thoracic surgeon calls a gynaecologist after diagnosing endometriosis, hormonal suppressive therapy should be instituted.  Less than 1/3 of women with catamenial pneumothorax have concurrent pelvic endometriosis55.   Routine hysterectomy with bilateral oophorectomy in these patients may necessitate subsequent oestrogen therapy for menopausal symptoms which could activate lung lesions41.  This should be avoided. 

surgical pleurodesis is the treatment of choice.   

Catamenial haemoptysis: This is a very rare condition and the leading clinical symptom of tracheo-brochial or pulmonary parenchymal endometriosis33. The most important criterion of diagnosis is the patient’s history of catamenial symptoms. Chest X-Ray may be normal, but may, in some cases show solitary or multiple pulmonary nodules with cyclical changes in size. Chest CT scans are more useful and can reveal ill-defined local infiltrates, well-defined nodular densities and cystic lesions, which may change in size during the menstrual cycle. The diagnostic use of bronchoscopy is said to be limited, as most cases of pulmonary endometriosis involve the distal pulmonary parenchyma rather than the mucosa of the large bronchi, and the bleeding site may only be evident during the menses .  However, Wang et al described 4 cases of bronchoscopic biopsy and diagnosis of tracheobronchial endometriosis, which were subsequently treated with Danazol42

Lung nodules: Lung nodules as a variant of parenchymal lung endometriosis are rarer than hemoptysis.  Although chest radiographs often show normal findings, they can also reveal solitary or multiple nodules, cystic defects and opacities displaying cyclical changes in size. CT findings in pulmonary endometriosis include ill-defined


Endometriosis at other sites



Liver Endometriosis:

Endometriosis of the liver was first described in 1986.  Patients diagnosed with liver endometriosis have usually presented with pain, with H/O endometriosis before.  The presence of space occupying lesions in the liver of unknown eitiology should alert the physician of the possibility of liver endometriosis.  There may be subsequent ascites,portal vein thrombosis and jaundice.  Endometrial Stromal sarcoma of the liver has been described25.  Treatment is by surgical resection.  Prognosis of Endometrial Stromal Sarcoma depends on the mitotic index of the tumour. 

Diaphragmatic endometriosis13:

Cucinella et al have described a case of a young girl with cyclical right shoulder pain, responding partially to anti-inflammatory drugs and contraceptive pills, with concomitant pelvic endometriosis.  At the time of laparoscopy for pelvic endometriosis, two endometriotic lesions were found on the diaphragm on the right hemi diaphragm.  They were cauterized, as they seemed far away from the ventricles of the heart.  The patient was relieved of her symptoms. 

In patients with pelvic endometriosis, rotating the laparoscope to look for lesions in the diaphragm could be useful in symptomatic patients, complaining of cyclical shoulder pain.  Experienced laparoscopic surgeons could cauterize the lesion after ascertaining that surrounding organs are not damaged. 

Endometriosis of the Alcock’s canal56:

In patients with endometriosis of the rectovaginal septum, the inflammation surrounding the endometriotic nodule could sometimes entrap the pudendal nerve entering the  Alcock’s canal, which is the space bound laterally by the ischium and medially by the obturator internus aponeurosis (ischiorectal fossa).The pudendal nerve comprises sacral roots S2, S3, and S4, and gives rise to the perineal nerve, which innervates anal and urethral external sphincters, and perineal and vulvar skin in women. Pudendal nerve entrapment causes pain in the lower central pelvic areas (anus, perineum,  or vulva). Pain can affect one, several, or all areas, and is usually worse in the sitting position. Frequently, there is also urinary or anal incontinence and sexual dysfunction.

Patients with endometriosis of the alcock’s canal may present waith sciatica like pain assossiated with menstrual periods.  Physicians should be alert to the possibility of endometriosis when patients complain of cyclical sciatica like pain.  Symptoms can be relieved with GnRh Analogue therapy.


Endometriosis with Ascites:

Endometriosis with ascites is very rare and it presents a diagnostic dilemma for the clinician. Only sporadic cases have been reported. Exact cause is not known, but irritation of the peritoneum with blood and endometrial cells, obstruction of  lymphatics in the diaphragm have all been put forward as theories. In most of these cases, a diagnostic laparotomy/laparoscopy and histopathologic confirmation of the diagnosis is required.  Definitive management involves surgical removal of endometriosis tissues followed by long-term hormonal suppression therapy.  Patients who undergo conservative surgery or medical management need close

follow-up after stopping medical treatment because recurrence can occur when the hormonal suppression

is withdrawn. There is a rare chance for developing malignancy as endometrioid or clear cell carcinoma,

especially in atypical endometriosis. The reported frequency of malignant transformation is 5–10%. 

Inguinal Endometriosis:

Endometriosis in the inguinal region was first reported by Cullen in 1896.  Giovanni et al. reviewed 958 patients who underwent clinical evaluation for endometriosis and reported that the incidence of endometriosis in the inguinal region was 0.6%20.  Endometriosis in the inguinal region is mostly associated with inguinal hernias, and tends to predominate on the right side, probably because the sigmoid colon partially protects the left groin.  There usually is concomitant pelvic endometriosis.  The canal of Nuck, which is a dilatation of peritoneum that accompanies the round ligament and extends from the inguinal canal into the vulva, is probably the the site through which pelvic endometriosis extends into the inguinal canal. MRI is a useful diagnostic modality in diagnosing this disease entity.  Wide excision by the inguinal route is the treatment of choice.  Concomitant laparoscopy may be necessary to rule out pelvic endometriosis.

Endometriosis in post menopausal women:

 Endometriosis is said to be a estrogen dependent disease, which is expected to regress after menopause.  However, it can affect 2-5% of post-menopausal women31.  It may follow hormone replacement therapy, as endometrial lesions get activated with the estrogen therapy.  This is specially so, since standard treatment dictums warrant bilateral salpingo-oophorectomy for complete eradication of disease and this leads to severe post-menopausal symptoms.  Generally due to absence of uterus and lack of fear of endometrial hyperplasia, progesterone add-back therapy is not given.  This can aggravate the stimulation of endometriotic foci which may have developed anywhere in the body.

Endometriotic ovarian cysts and rectal nodules have also been reported in post-menopausal women without any history of hormone replacement therapy.  They may present with pelvic pain or with a mass in the abdomen.  Although surgery in the late post-menopausal period is risky due to multiple medical complications associated with old age, surgical therapy may be the only solution for such patients. 




 Endometrium, destined to proliferate and shed from the uterus has been recorded to have reached almost all organs of the body.  Thus endometriosis can occur in almost any organ of the body.  Cyclical symptoms occurring in a woman should alert the physician to the possibility of endometriosis. Symptoms occurring in distant organs like the lungs or small intestine or cutaneous endometriosis may lead the patient to visit specialists concerned with those organs.  However, a gynaecologist may be called in to perform hysterectomy or supervise hormone therapy, with which the non-gynaecologist may not be familiar. 

Quite often women are more comfortable visiting gynaecologists as primary physicians, when difficult situations arise, as they have a bonding with them through deliveries or subsequent illnesses.  In these instances,  gynaecologists who are faced with cyclical symptoms occurring in other organs should be alert to the possibility of endometriosis in rare places, and should be aware of the treatment possibilities of endometriosis occurring in these organs, to guide the patient properly.



1.Patterson.G.K,Winburn.G.B: Abdominal wall endometriomas,Report of eight cases: The American surgeon.1999;65: 36-39.

2.Z.Zhu.M.A.M, Al-Beiti,et al. Journal of Obstetrics and Gynaecology 2008; 28(7): 742–745. 

3. Hélène Nehme-Schuster, Cherif Yousse, et al : Lancet 2005; 366: 1238.

4. Mordadi.P,Barakate.M,et al, Intussusception of the vermiform appendix due to endometriosis presenting as acute appendicitis: ANZ J. Surg. 2007; 77: 758–760.

5.AgarwalN, Kripalani.A,et al.: J. Gynecol Surg2002; 18:69.

6.Papafragaki.D, ConcannonL: J.of women’s health2008;117:3: 367-372.

7.Peikert.T, Gillepsie.DJ,Catamenial pneumothorax: Mayo Clin Proc. 2005;80(5):677-680.

8.Shawky.Z.A,Badawy.MD et al., Cervical Endometriosis Stimulated by Estrogen Therapy

Following Supracervical Hysterectomy: J GYNECOL SURG ;Volume 19, Number 3, page 141;2003

9.Hoang CD,Boettcher.A.K, An Unusual Rectosigmoid Mass: Endometrioid Adenocareinoma Arising in Colonie

Endomietriosis: Case Report andLiterature Review:The American Surgeon, Vol71,NO8,PP694-697,Aug.2007.

10. Das K, Majhi TK, Chattopadhyay SD. Vesical endometriosis with Lt. sided hydroureteronephrosis. Indian J Surg


11.Luisi.S,Gabbanini.M,et al., Surgical scar endometriosis after Cesarean section: A case report: Gynecological Endocrinology, May 2006; 22(5): 284–285.

12.S.KKang, M.W.Lee, et al., Cutaneous endometriosis: a combination of medical and surgical treatment: J. Dermatol Treat 2002: 13:189-192.

13. Cucinella.G,Granese.R., Laparoscopic treatment of diaphragmatic endometriosis causing chronic shoulder and arm pain: (Letters to editor): Acta Obstetricia et Gynecologica. 2009; 88: 14181419.

14.Isbister.WH,Endometriosis in an episiotomy scar preceding pelvic endometriosis: ANZ J. Surg. 2002; 72: 314–315.

15. De Oliviera.MA,DeLeonAC, Risk factors for abdominal scar endometriosis after obstetric

hysterotomies: a case_control study: Acta Obstetricia et Gynecologica. 2007; 86: 73-80.

16. D. Wickramasekera,D.J,Hay et al: Acute small bowel obstruction due to ileal endometriosis: a case report and 

    literature review: J.R.CoU.Sttrg.Editth.. 44. Feb 1999. 59-60.

17.Sengul I, Sengul D: Can.J.Surg.Oct.2009:Vol52.No5, pp444-445.

18.Avellanet.Y.R,Koh.C: Primary Infertility Associated with Abdominal Wall,Bowel, and Pelvic Endometriosis: J Gynecol Surg Vol27:NO1,PP:45,2011.

19. RS Low,1 AO Jones et al: Endometriosis of the inguinal region: Magnetic resonance imaging (MRI) findings: Australasian Radiology (2007) 51, B272–B275.

20.HagiwaraY,Hatori.M: Inguinal endometriosis attaching to round ligament: Australasian Radiology (2007) 51, 91–94.

21.KellyP,McCluggage.W.G, Intestinal endometriosis morphologically mimicking colonic adenocarcinoma: Histopathology 2008, 52, 510–514. 

22.Ponsford.AM,WeidnerN, Colonization of Intestinal Endometriosis by Benign Colonic Mucosa: A Pattern

     Potentially Misdiagnosed as Invasive Mucinous Carcinoma : International Journal of Surgical Pathology

      19(2) 259–262.

23. Lowe.P.J, Burmeister.L, Intestinal ovarian fistula associated with endometriosis: Journal of Obstetrics and

    Gynaecology (1998) Vol. 18, No. 2, 196- 197.

24.OffodileA,Hodgin.J.B, Asymptomatic Intussusception of the Appendix Secondary to Endometriosis: The American Surgeon,March 2007, Vol73,NO3,299-301.

25. KhanA.W, Craig.M, Liver tumours due to endometriosis and endometrial stromal sarcoma: HPB 2002 Volume 4, Number 1 43–46 © 2002 Martin Dunitz Ltd.

26.ThomasC, Steele.A, Cervical endometriosis following Large Loop excision of the Transformation Zone: J 

     Gynecol Surg 1999,15:61.

27.Simsir.A,Thorner.K et al: Endometriosis in Abdominal Scars: A report of Three Cases Diagnosed by Fine- 

     Needle Aspiration Biopsy: The American Surgeon. Oct 2007,Vol.67,NO.10,984-987.

28.JenniferN,Edie.D et al: Occurrence of Primary Umbilical Endometriosis and Recurrent Catamenial  

       pneumothorax.: Journal of Gynecologic Surgery; Jun2011, Vol. 27 Issue 2, p95-98, 4p.

29.Shweiger.W,BacherH, Perianal Endometriosis with Involvement of the External Anal Sphincter, Eur J Surg 1999;

      165: 615–617.

30.Laird.LA,Hoffman JS, Multifocal Polypoid Endometriosis Presenting as Huge Pelvic Masses Causing Deep   

     Vein Thrombosis. Arch Pathol Lab Med. 2004;128:561–564. 

31.Rosa e Silva JC,CarvalhoB.R, et al, Endometriosis in postmenopausal women without previous hormonal

     therapy: report of three cases: Climacteric 2008;11:525–528.

32. OxholmD,Knudsen UB, Postmenopausal endometriosis: Acta Obstetricia et Gynecologica. 2007; 86: 1158-1164.

33. Park.YB, Heo.GM, Pulmonary endometriosis resected by video-assisted thoracoscopic surgery: Respirology   

      (2006) 11, 221–223. 

34.Kilgus M, Schob R et al., Rectal Endometriosis: Transanal Endoscopic Microsurgery or Laparoscopic Resection?

     Eur J Surg 1998; 164: 231–232.

35.PapaziogasT,Papaziogas B et al., Endometriosis of the Rectus Abdominis muscle after Caesarian section: 

      Eur.Surg. 2002, Vol34,NO:3, PP203-205.

36.Neri.I, TabanelliM, Diagnosis and treatment of Post-caesarian Scar Endometriosis: .4cla Derm Venereol2007,  

      87: 428-429.

37. Jamabo.RS, Oga RN, Abdominal Scar Endometriosis: Indian J. Surg. (July-August 2008) 70:184–187.

38. Loverro G, Cormio G et al, Perforation of Sigmoid Colon during pregnancy: A rare complication of

      Endometriosis ., J Gynecol Surg:1999, 15:155.

39.Curry.TW: Subcutaneous Endometriomas: Two case reports and review of th  literature: J Gynecol Surg: 


40.Lois ED, Carvounis E.E, Subhepatic retroperitoneal endometrioma: Report of a case: Gynecological 

    Endocrinology, August 2007; 23(8): 479–481.

41. Yuen JS, Chow PKH, Unusual sites(Thorax and Umbilical hernia) of endometriosis: J.R.Coll.Surg. Edinb., 46  

    October 2001, 313-315.

42. Wang HC, Kuo PH, Catamenial haemoptysis from Tracheobronchial endometriosis:  Chest2000:118:1205-1208.

43. AyhanA, Karmursel BL et al., Three Cases of Urinary-Tract Endometriosis with Different Clinical Findings:J

      Gynecol Surg 16:149,20000.

44.Carter S,DavidsonT et al: A case of spontaneous umbilical endometriosisJournal of Obstetrics and Gynaecology 

    (1998) Vol. 18, No. 5, 490- 491.

45. RazziS, RubergniP, Umbilical endometriosis in pregnancy: a case report: Gynccol Endocrinol 2004; 18:114-116.

46.LoverroG,Mei L et al, Umbilical Endometriosis: J Gynecol Surg: 17:65, 2001.

47.Ponticelli.C,Graziani.G et al., Ureteral Endometriosis: A Rare and Underdiagnosed Cause of Kidney

      Dysfunction: Nephron Clin Pract 2010;114:c89–c94.

48. Leonhartsberger.N, ZelgerB, Intrinsic Endometriosis of Ureter and Bladder in Young Women without

      Gynecological Symptoms: Urol Int 2008;80:222–224.

49.Watanabe.Y,Ozawa H et al, Hydronephrosis due to ureteral endometriosis treated by transperitoneal laparoscopic

      ureterolysis: International Journal of Urology (2004) 11,     560–562.

50 Pal DK: Urinary tract endometriosis: Indian J Surg 2004;66:41-3..

51.Zache G,TonniG, Endometriosis of the abdominal wall: a clinical-pathologic contribution: Journal of Obstetrics

     and Gynaecology (1997) Vol. 17, No. 3, 301-302.

52. BroughRJ,FlynnKO, Recurrent pelvic endometriosis and bilateral ureteric obstruction associated with hormone  

      replacement therapy: BMJ May 1996, VOLUME 312 page:1221.

53.GoelP, Sood.S.S et al: Caesarian  scar endometriosis-Report of two cases: Indian J Med Sci, Vol. 59, No. 11,  

     November 2005.

54.KiyanE,KilicalsanZ: An Unusual Radiographic finding in pulmonary parenchymal  endometriosis: Acta Radiologica 43 (2002) 164–166.

55.Alifano.M,Roth T et al, Catamenial pneumothorax: A prospective study: Chest 2003;124:1004-1008.

56.Schuster.H,Youssef.C,, Alcock’s canal syndrome revealing endometriosis:   

     Vol 366 October 1, 2005.

57.cucinellaG, Cal



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