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Case 200

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Female patient, 34 years of age, never been pregnant, attended the gynecology service reporting infertility. Refers menarche at age 13, regular cycles and normal menstrual flow. Denies dyspareunia or pelvic pain. Presents hypothyroidism clinically controlled with levothyroxine. Physical examination and laboratory review unremarkable, except for the serum levels of CA-125: 91.2 IU / mL (Reference value: 35 IU / mL). Transvaginal ultrasonography (US) was requested (Image 1). Due to the findings, was prescribed the use of oral contraceptives (OC) for 6 months, however, there was no resolution of the infertility.

Based on the clinical history and the imaging studies presented, which is the most likely diagnosis?

a) Hemorrhagic luteal cyst

25%

b) Ovarian teratoma

25%

c) Mucinous cystadenoma

25%

d) Endometrioma

25%
   

Image analysis

 

Image 1: Transvaginal Ultrasonography surveying the left ovary, showing a cystic, oval formation with well-defined walls, filled with low-level echoes, measuring 3.8 x 3.0 x 3.5 cm - Volume 21,8cm3. Doppler study showed flow restricted to the periphery of the structure.

Highlights 

- The endometrioma is a benign cyst, which corresponds to a localized form of endometriosis, affecting mainly the ovaries.

- Might be associated with female infertility.

- The diagnosis is clinical and by ultrasound, although the final confirmation is histological.

- Magnetic resonance imaging is indicated for bigger cysts and preoperative evaluation.

- Treatment may be expectant, with the use of drugs, or therapeutic, which is surgical.

- Surgery should be reserved for large endometriomas and symptomatic patients.

- In vitro fertilization (IVF) is not adversely affected by the endometrioma.

References

- Carnahan M, Fedor J, Agarwal A, Gupta S. Ovarian endometrioma: guidelines for selection of cases for surgical treatment or expectant management. Expert Rev. Obstet. Gynecol. 8(1), 29–55, 2013. 

- Filho AC, Melhem MEV, Loureiro FL, Duarte SR, Brasil AN, Almeida SMB. Tratamento do Endometrioma Ovariano:Opções, Resultados e Conseqüências. Femina - vol 34 nº 06, 395-399, 2006.

- Levy BS, Barbieri RL. Diagnosis and management of ovarian endometriomas. UpToDate 2015. [Access in July, 2015]. Available at http://www.uptodate.com/contents/diagnosis-and-management-of-ovarian-endometriomas.

- Andrade FN, Palma-Dias R, Costa FS. Ultrassonografia nas massas anexiais: aspectos de imagem. Radiol Bras.; 44(1):59–67, 2011.

- Martins WP, Barros ACM, Barra DA, Filho FM. Ultra-sonografia na condução de massas pélvicas. FEMINA, vol 35, nº 6, 345-349, 2007.

Authors

Fernando de Carvalho Bottega, fifth year medical student at UFMG.

E-mail: f.cbottega[at]hotmail.com

 

Fabio Mitsuhiro Satake, fifth year medical student at UFMG.

E-mail: fabiosatake[at]gmail.com

Supervisors

Eduardo Batista Cândido, professor of the Department of Obstetrics and Gynecology of UFMG

E-mail: candidoeb[at]gmail.com

Reviewers

Barbara Queiroz, Julia Petrocchi and professor Viviane Parisotto.

Translated by

Bárbara de Queiroz e Bragaglia, sixth year medical student at UFMG. E-mail: barbara.bragaglia[at]ufmg.br

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