Clinical history: 46 year old female presented with ovarian cyst and pelvic pain radiating to the back.
What is the diagnosis?
Grossly, small, raised, red to brown to blue spots on ovarian surface with fibrinous adhesions. Chocolate cysts due to repeated hemorrhage may also be present. To diagnosis endometriosis, 2 out of 3 features are required: endometrial glands, endometrial stroma or hemosiderin-laden macrophages. In our case, all the features are present. Stromal cells have naked nuclei and are surrounded by reticulin and spiral arterioles. Smooth muscle stroma is also common. In some cases, the specimen may be composed of necrotic, pseudoxanthomatous nodules. Rarely, the presentation is that of polyp, a condition called polypoid endometriosis, which is usually associated with non-polypoid endometriosis.
Endometriosis occurs in 10% of women in western countries. The risk factors are younger age group, high socioeconomic status, no oral contraception, nulliparity, short menstrual cycles, abundant menses and positive family history. It accounts for 25% of laparotomies and laparoscopies by gynecologists, second in frequency only to leiomyomas. Ovary is the most common site of involvement. Two main hypotheses based on retrograde menstruation: implantation of endometrial cells on peritoneum (favoured "metastatic theory") or peritoneal stimulation by substances released by shed endometrium (alternative "metaplastic theory").
The classic clinical triads are dysmenorrhea, dyspareunia and infertility. Abdominal or pelvic pain frequently extends to the back. Elevated CA-125 may be seen. Endometriosis may be associated with significant morbidity. Although endometriosis is the best documented precursor of 20% of ovarian carcinomas, the risk of malignant transformation is negligible. Carcinomas associated with endometriosis are most often endometrioid (70%) and clear cell (14%), particularly if endometriosis is associated with atypical hyperplasia.