An image of the first woman to develop endometriosis of the vulva following vaginal hysterectomy. Most cases develop in episiotomies following vaginal birth. The image is of the vulva post successful medical treatment of her endometriosis. The biopsy site is marked with an arrow and she was not bleeding at the time of the photograph.
A 39-year-old woman presented in with cyclical bleeding, thought to originate from the vagina, of a similar duration to her previous menstrual cycle. She underwent a vaginal hysterectomy without salpingectomy in for menorrhagia and a 15cm fibroid uterus but claimed to have experienced cyclic bleeding since. The operation notes did not indicate any superficial vulval trauma occurring during the surgery and no episiotomy was performed for access. No endometriosis or adenomyosis were noted in the original hysterectomy or histology report.
Initial examination failed to detect any pathology however repeat examination at the time of symptomatic bleeding revealed a small area of vulval redness in the right periurethral region. Speculum and vaginal examinations were again normal. This lesion was confirmed to be endometriosis on biopsy.Due to the subtle nature of the lesion and that the area had been excised clinically; the patient was advised to undergo medical management in an effort to avoid further surgery. She was commenced on six months of 2mg dienogest tablets daily with complete alleviation of her symptoms.
Hysterectomy requiring morcellation may have been the mechanism for development of vulval endometriosis however this is a rare occurrence.
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