Just a quick
update to highlight a case report I find particularly important when
considering the origin of endometriosis. This case report from the US is
of a pregnant woman who, after a scan at 35 weeks, was told that her unborn
child had a large abdominal mass measuring roughly 6.5 x 4.8cm, a mass which
there was no sign of at the 20 week scan. A further scan at 37 weeks revealed
that the mass, which had all the hallmarks of a large cyst, had grown to 7.8 x
6.8cm. No doubt fearing for the health of both mother and unborn child, the
decision was made to induce the pregnancy at 38 weeks. After delivery the
infant was operated on, the cyst removed and was otherwise perfectly healthy.
Analysis of
the cyst revealed the tell-tale signs of an ovarian endometriotic cyst i.e. a
thin walled cyst filled with reddish-brown fluid, which the pathologist later confirmed.
Ovarian cysts in unborn females foetuses are not unheard of, but are extremely
rare and endometriotic cysts even rarer, in fact this is the first case I’ve
seen reported.
I have
though, seen reports on microscopic endometriosis being found unborn female
foetuses and talked about them here.
However, these findings usually describe very small areas of endometriosis,
hardly what you could call ‘mature’ disease. This most recent case is
particularly unusual then as it represents what’s is termed ‘advanced’ stage
endometriosis (although in reality there is some contention as to whether
endometriosis is a progressive disease and therefore whether words like ‘early’
and ‘advanced’ stage endometriosis are even relevant). Certainly this case
casts doubt on the assumed notion that endometriosis progresses to further
stages as you get older.
Furthermore,
this raises more questions about the origin of endometriosis. The accumulating
evidence suggests that endometriosis is a dormant developmental disorder;
something with which you are born that becomes active around the time of
puberty. How, when and why the symptoms associated with endo come into being is
another matter altogether. How endometriosis arises during development is
another big question. Displacement of stem cells? Abnormal growth of portions
of the reproductive organs? Early menstrual influences before birth? Yes, you
read that last part right. The uterus of new-born females is capable of
undergoing something akin to menstrual changes and menstruation. Of the very
few studies that have
looked into this, the general finding was that visible bleeding was observed in
around 5% of new-born females, caused by exposure to, and withdrawal from, the
mothers hormones. This may lead to a sort of prenatal retrograde menstruation
of endometrial cells, planting the seeds of endometriosis in the pelvis before
birth. Of course, there are still many stumbling blocks to overcome before any
theory on the origin of endometriosis is widely accepted, some of which I’ve
touched upon previously.
Title from
Thomas Hardy’s poem ‘How Great my Grief’
