Incidence of endometriosis is around 10 to 15% in women of reproductive age group. Umbilical endometriosis is a very rare entity. Extra genital endometriosis accounts to 3% of endometriosis. Incidence of umbilical endometriosis is 0.5%-4% of extra genital endometriosis. 30 years old multi gravida was referred to our hospital with c/o periodic bleeding from the umbilicus for the past 3 months. She was also having dysmenorrhoea for about 3 months. On examination, patient had a small bluish nodule in the umbilicus around 1.5x1.2 cm in size. Clinically there was suspicion of pelvic endometriosis as the uterus was retroverted and fixed. CT abdomen showed a small hypo-echoeic area in the umbilicus and uterus was adenomyotic with normal ovaries. Patient was given the option of laparoscopy and excision of umbilicus, as there was suspicion of peritoneal endometriosis and the patient also insisted upon laparoscopic sterilization. Laparoscopy showed early peritoneal endometriosis with pelvic adhesions and the same adhesiolysis was done along with cauterization of endometriosis. Sterilization was also done as per the patient’s request. Umbilical excision and layer closure was done. Umbilical endometriosis is a rare entity. This patient had associated early pelvic endometriosis. Umbilical endometriosis could be secondary to the lympho vascular spread from the pelvic endometriosis or primary umbilical endometriosis. History, clinical and imaging were pointing towards umbilical endometriosis. Surgical excision of umbilical endometriosis and cauterisation of early pelvic endometriosis were done. Patient needs follow up. Umbilical endometriosis may be primary or secondary which needs total excision and follow up.
Copper T is one of the widely used intra uterine contraceptive devices due to its safe, effective and reversible nature. It has also been widely used as it is cost effective too. Copper T is usually inserted immediate post-partum, post abortal, during the proliferative phase of any menstrual cycle or 6 to 8 weeks following post-partum. Complications associated with use of Copper T include heavy menstrual bleeding, pelvic inflammatory disease, uterine perforation, displacement and rarely, transmigration. Post-insertion of copper T, women need to have regular follow up visits to prevent such complications. Patients should be advised to check for the presence of threads periodically. Considerable number of patients with transmigration of copper T has been reported in literature. Sites into which transmigration has been reported include broad ligament, ovarian fossa, urinary bladder, sigmoid colon, rectum, peritoneum, omentum, pouch of douglas, retro peritoneal space, iliac veins, ovaries, appendix and rarely in the abdominal wall. Transmigrated copper T may be diagnosed with ultrasonogram, X-ray and CT scan. Copper containing intra-uterine devices are known to provoke inflammatory reactions and symptoms depending upon the sites to which they have been transmigrated. Hence, we should resort to early intervention and remove the misplaced copper IUCD at the earliest. Here, we are reporting a rare case of transmigration of copper T into the anterior abdominal wall elaborating on various facets of copper T including its advent, incidence of use, efficient diagnosis and well-planned retrieval.
Anomalies of female genital tract may not be detected until after menarche when they present a cyclical pain due to outlet obstruction. Mullerian anomalies represent a vast array of structural abnormalities resulting from improper development and fusion of embryological mullerian ducts. 19-year-old girl attained menarche at the age of 14, had progressive dysmenorrhoea and diagnosed as right haemotosalphinx and ovarian endometrioma which were removed in 2008. As pain progressed, she underwent laparoscopic adhesiolysis in 2013. Since, pain persisted, diagnosed as right haematometra, and drainage done by laparotomy. Left adnexa were normal. She was given depot provera till she completed schooling. She developed recurrent dysmenorrhoea after stopping depot provera. USG and MRI revealed recurrent haematometra on right side with normal left horn. The possibility of atypical septum was thought about and hystero laparoscopy was done. It showed right side haemetometra with absent right adnexa. Left adnexa normal. Hysteroscopy showed normal left horn with septum with a bulge towards the left side. Hence, proceeded with hysteroscopic septostomy and haemetometra was drained to the left horn. Later patient was free from dysmenorrhea and repeat hysteroscopy was found to be normal. This case highlighting mullerian anomalies have to be considered when young girls present with severe progressive dysmenorrhoea and diagnosis remains a challenge most of the clinicians. This rare entity has to be kept in mind while evaluating such patients. Prompt diagnosis and early surgical correction are essential to avoid future morbidity in the form of repeated unnecessary surgeries.
Endometriosis causes severe pain and infertility affecting quality of life. According to ASRM it is a chronic inflammatory disease that requires life-long management plan and surgery has to be restricted only once in the life time of the patient. Earlier, the diagnosis of endometriosis was confirmed by surgical method and histo-pathological examination. There is often a diagnostic delay up to 7 years or even beyond, which will affect the patients getting earlier treatment. Recently, lot of non-invasive techniques for diagnosis of endometriosis have come into vogue so that, treatment can be planned without surgical diagnosis. Apart from imaging through USG, CT or MRI, earlier lesions can be picked up by biomarkers like IL-6, IL-8, CA 125, HE4, neutrophil-lymphocytic ratio, Hs-CRP, Tumour necrosis alpha and mi RNA, neural elements in endometrium, glyco-proteins like CA-125, CA-19.9, CA-15.3, CA-73, AFP and CEA. Urocortin, activin and follistatin are growth factors and VEGF, TNF-alpha, NK cells, i-SCAM-I, MCP-1 are immunologic markers for diagnosis of endometriosis. Circulating endometrial cells are also present in the peripheral blood of patients. miRNA in endometriosis is found to be a potential biomarker in the recent years and also associated with altered vaginal microbiome. There has been up-regulation and down-regulation of certain miRNAs in endometriosis patients. In patients with symptoms of endometriosis, miRNA study in peripheral blood can be used as a biomarker for confirmation of diagnosis. There is a strong association between mitochondrial DNA variation and endometriosis which is found to be rational biomarkers.
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