71. Case Report: Vaginal Endometriosis After Treatment of an Imperforate Hymen

Abstract

<h3>Background</h3> Obstructive anomalies at any level of the reproductive tract increase the risk of endometriosis. While endometriosis may improve after relieving the obstruction, persistent endometriosis has been reported. While not common, vaginal endometriosis may occur in adolescents. A case of vaginal endometriosis in an adolescent with history of imperforate hymen is presented. <h3>Case</h3> A 14-year-old, never sexually active, female presented to a tertiary pediatric and adolescent gynecology clinic with secondary amenorrhea. She reported one episode of vaginal bleeding 4 months prior to presentation and had noted a "bulge" at her introitus for 1 year prior to the bleeding episode. She sought gynecologic care for the secondary amenorrhea and was diagnosed with an imperforate hymen and hematocolpos (Figure 1). She underwent a hymenectomy – notable for 800mL of menstrual blood, a dilated single cervix, and normal appearing vaginal mucosa. Her post-operative course was uncomplicated. She had monthly menses without dysmenorrhea. Three months after the hymenectomy she complained of painless intermenstrual vaginal bleeding that occurred after bowel movements. She had a history of constipation. An external genital exam and bimanual exam were unremarkable. A speculum exam was significant for diffuse red friable lesions on the vaginal mucosa and cervix which appeared similar to endometriosis (Figure 2). Her hymenectomy site was well healed. Constipation treatment was initiated. She underwent an exam under anesthesia and biopsy of the vaginal lesions. Pathology confirmed endometriosis. Progestin only pills (POPs) were started for hormonal suppression. Resolution of the vaginal bleeding with bowel movements occurred, however she initially struggled with pill compliance and breakthrough bleeding with POPs. At her most recent visit, she was doing well with minimal breakthrough bleeding, no bleeding after bowel movements, and no dysmenorrhea. She continues to treat her constipation. <h3>Comments</h3> The risk of endometriosis with obstructive outflow tract anomalies is well known, however, painless vaginal bleeding is not the typical presentation of adolescent endometriosis. While providers must consider other etiologies of vaginal bleeding in the adolescent, endometriosis should be included in the differential – particularly in women with a history of an outflow tract obstruction. Medical management using hormonal suppression to reduce the risk of endometriosis proliferation is recommended for adolescents with endometriosis – thereby achieving the overall goals of therapy: minimizing pain symptoms and maximizing quality of life and future fertility.