Here there and everywhere

I’ve mentioned a few times throughout this blog about the occurrence of extra-pelvic endometriosis, that is, endometriosis that occurs in places you wouldn’t usually expect to find it. Whilst this is a relatively rare presentation of endometriosis, recently there seems to have been a glut of publications about this vey subject, so I thought it would be worth jumping on the bandwagon and writing a bit more about it.

I’ll start with, what appears to be, the most common type of extra-pelvic endo; abdominal scar endometriosis. Women with endo are far more likely to have surgeries that leave them with abdominal scars, such as laparoscopies, laparotomies and hysterectomies; so surgeons need to be made aware of the risk and protocols need to be established in order to minimise the occurrence of scar endo. At the same time, doctors need to be made more aware of extra-pelvic endometriosis so it can be recognised and treated quickly.

The first study is a report of three cases of abdominal wall scar endometriosis after caesarean from the Romanian Journal of Morphology and Embryology. The authors make an important point, which is that scar endo is ‘iatrogenic’, meaning that it is a condition caused by a medical procedure. I hate to sound like I’m repeating myself, but this is something that surgeons really need to be aware of. Then there is another report of something similar from Ginekol Polska (Eastern Europe seems to be a great place for extra-pelvic endo awareness at the moment). This report doesn’t specify which surgical procedure was performed (in the abstract anyway), rather just states endometriosis was found in a pfannenstiel incision, which refers to a large abdominal incision much like you would get from a caesarean section or laparotomy.

Following on from that, here are two cases of mistaken identity. A recent study reported a case of endometriosis of the appendix mimicking appendicitis. Although this could have led to some very serious problems, fortunately surgical removal of the appendix proved effective. Finally, there is a case report of a woman who was thought to have rectal cancer, but upon investigation was found to have rectal endometriosis. The reported involvement of endo in the lymph nodes of this case is significant as it suggests the endo may be quite invasive.

The only way to diagnose extra-pelvic endometriosis is histologically; this means cutting a piece of the suspect tissue out and examining it under a microscope to see if it looks like endometriosis. Similarly, the only way to treat extra-pelvic endometriosis is surgical removal. This, of course, sounds rather counter intuitive. If you have scar endometriosis, the last thing you think you’d need is to be cut open again. Because, whilst this would remove the endometriosis, it would create a fresh scar that may end up forming more scar endo later on, which you would then need more surgery for; it’s a situation so circular it’ll make your head spin.

There are also the inherent risks that multiple surgeries carry to consider. This paper rightly points out that repeated surgical incisions, particularly in the abdomen, may lead to increased risk of hernias, abscesses, lipoma (a benign fatty tumour) and granuloma (a mass formed by the body in order to contain a foreign substance).

So perhaps it is time to start looking at less radical methods for excision of extra-pelvic endometriosis. It is also important to be aware of the symptoms of extra-pelvic endometriosis. If you notice any pain that comes on a cycle accompanied by changes in skin colour/texture/sensitivity/inflammation it is definitely worth having these symptoms investigated.

If anyone is interested in some further reading, there is a good free-text article on extra-pelvic endometriosis here.

Getting under your skin

Endometriosis can be found pretty much anywhere in the body (I’m going to do a separate post on that at some point, but I digress) for this post though I’ll be focussing on endometriosis of the skin, or cutaneous endometriosis as it is known. There have been several reports of endometriosis found on the skin, although the phenomenon is still considered rare, reports of this subtype of endometriosis go back to the 50’s. Most commonly cutaneous endometriosis is found on surgical scars and around the umbilicus (belly button/navel). Symptoms typically include cyclic pain emanating from a mass near/on a scar or the umbilicus and can be misdiagnosed as suture granuloma, lipoma, abscess, cyst, hernia or skin cancer.

Let’s take a look at reports of some typical examples; three years after having a caesarean section a 37 year old woman found a nodule under her scar that became painful during menses. The nodule was removed surgically and after examination it was found to be cutaneous endometriosis. Another report found a woman with dark brown mass on the umbilicus associated with cyclic pain. Although the woman was found not to have pelvic endometriosis the mass on her umbilicus was found to be endometriosis.

The reason for me discussing cutaneous endometriosis is that a paper has recently been published in Brazil that suggests caesarean section greatly increases the risk of endometriosis developing on the scar. The study looked at 72 patients diagnosed with scar endometriosis between 1978 and 2003. It was found that the risk of scar endometriosis developing was far higher after caesarean section, where the risk was 0.2%, than other procedures e.g. episiotomy, where the risk was 0.06%. There are several parallels that can be drawn between cutaneous endometriosis and pelvic endometriosis. Both conditions are often misdiagnosed, both present with cyclic pain and we still don’t really understand how the disease gets to where it is. As cutaneous endometriosis appears around scars it could be hypothesised that somehow fragments of endometrium find their way into the open wound during surgery where they later form endometriotic implants.

The good news though is cutaneous endometriosis can be easily removed with surgery and once it is gone it usually doesn’t come back.