{"paper_id":"1250003b-053c-42d5-bfc0-7d484baeb383","body_text":"Case Report  | JOGCR. 2025; 10(10): 803-809 \n     Volume 10, October 2025       Journal of Obstetrics, Gynecology and Cancer Research \n Journal of Obstetrics, Gynecology and Cancer Research | ISSN: 2476-5848 \n \nCyclical Bleeding from an Abdominal Wall Scar: A Clinical Case of Scar \nEndometriosis \nGiddaluru Bhavya Muralikrishna , Karthiga Prabhu*  \n \n \nDepartment of Obstetrics and Gynecology, SRM Medical College Hospital and Research Center, Chengalpattu, India \nArticle Info  ABSTRACT \n  \n   10.24200/jogcr.10.10.803 \n \n \n \nScar endometriosis is a rare type of extra pelvic endometriosis characterized by \nfunctional endometrial tissue in surgical wounds, often occurring after obstetric or \ngynecological surgeries. It typically presents as a painful lump near the surgical scar, \nwith symptoms worsening during menstruation. We report a case of a 28 -year-old \nmultiparous woman who experienced cyclical pain and bleeding at the site of a previous \ntubal ligation for two years. Clinical examination showed a tender, nodular swelling \nwith active bleeding during menses. Imaging revealed a vascular lesion near the rectus \nmuscle, confirming scar endometriosis. A wide surgical excision was performed, and \nhistopathology confirmed endometrial tissue in the scar. The patient's recovery was \nsmooth, with no recurrence noted. This case underscores the need to recognize cyclical \nsymptoms at surgical scars as important indicators of scar endometriosis, highlighting \nthe significance of prompt diagnosis and treatment to prevent complications. \n \nKeywords: Endometriosis, Cicatrix, Abdominal wall, Gynecologic surgical \nprocedures, Menstruation -associated disorders \n \nReceived: 2025/05/22 \nAccepted: 2025/06/26 \nPublished Online: 05 Sep. 2025 \n \n \n \n \n \nCorresponding Information:  \nKarthiga Prabhu, \nDepartment of Obstetrics and Gynecology, \nSRM Medical College Hospital and Research \nCenter, Chengalpattu, India \n \nEmail: j.karthigaprabhu@gmail.com \n \n \n \nCopyright © 2025, This is an original open -access article distributed under the terms of the Creative Commons Attribution-noncommercial \n4.0 International License which permits copy and redistribution of the material just in noncommercial usages with proper citation . \n \n \n1. Introduction\nEndometriosis is characterized by the existence of \nfunctional endometrial glands and stroma located \noutside the uterine cavity, commonly presenting as \nchronic pelvic pain or infertility in women of \nchildbearing age (1). While endometriosis primarily \naffects pelvic organs (such as ovaries, peritoneum, and \nuterosacral ligaments), ectopic endometrial tissue can \nalso develop in areas outside the pelvis, including the \nabdominal wall, surgical scars, gastrointestinal tract, or \nthoracic cavity (2). Scar endometrio sis refers to the \nimplantation of endometrial tissue in or near a surgical \nscar, most frequently occurring after obstetric or \ngynecologic procedures (1). This condition is quite \nuncommon, as abdominal wall endometriomas make \nup less than 1% of all endometriosis cases. The \noccurrence of scar endometriosis after cesarean \ndelivery ranges from 0.03% to 0.8% in women \nundergoing a previous Cesarean section (2).  \nThe development of scar endometriosis is due to the \niatrogenic transplantation of endometrial cells during \nsurgical intervention. Viable endometrial cells from the \nuterus might be introduced into the incision (for \ninstance, during uterine incision closure in a Cesarean \nsection or other uterine surgeries) where these cells \ncould implant and eventually grow under hormonal \ninfluences (3). Over time, these implants can develop \ntheir own blood supply and may experience cyclical \nbleeding, resulting in the formati on of a localized \nendometrioma within the scar tissue. The risk factors \ninclude any surgical procedures that compromise the \nuterine cavity or fallopian tubes while endometrial \ntissue is present. Cesarean sections are the most \nfrequently seen precursor, although cases have b een \ndocumented after procedures like hysterotomy for \ntermination, myomectomy, tubal ligation, and even \nepisiotomies (3,4). A delay of several years between \nthe initial surgery and the onset of symptoms is \ncommon, with an average interval of around 3 to 5 \nyears in various studies (1,4).  \nIn clinical practice, scar endometriosis typically \nmanifests as a palpable subcutaneous nodule located at \nor near a scar, often accompanied by localized pain that \nworsens during menstruation (3). Patients may observe \na cyclical increase in size or tenderness of the mass at \nregular intervals. In rare cases, when the endometriotic \ntissue invades the dermis or epidermis, there can be \nactual bleeding or menstrual -like discharge from the \nscar, illustr ating the “menstruating scar” effect (5). \nSince there are various symptoms, which can resemble \nmore common surgical conditions (such as incisional \nhernias, stitch granulomas, abscesses, or tumors), \ndiagnosis frequently suffers delays or is overlooked \n(5). Here, we report a case of scar endometriosis in a \nyoung woman who had a tubal ligation scar and \nexperienced cyclical bleeding from the surface of the \nscar.  \n\n\nGiddaluru Bhavya Muralikrishna, et al. 804 \n      Volume 10, October 2025       Journal of Obstetrics, Gynecology and Cancer Research \n2. Case Presentation \nA 28-year-old female (gravida 3, para 2) visited the \ngynecology clinic with a two -year history of recurring \npain and bleeding from lower abdominal scar during \nmenstrual cycles. She reported experiencing sharp pain \nat surgical scar site for the first 2-3 days of each period, \nalong with spotting blood from the scar itself. The \nmenstrual cycles were regular (30 -35 days apart, \nlasting 3 days) with a normal volume and minimal \ndysmenorrhea apart from the localized pain at the scar. \nShe had two previous full -term normal vaginal births. \nIn 2018, the patient had a first -trimester surgical \nevacuation due to missed miscarriage, combined with \na bilateral tubal ligation via a mini -laparotomy \napproach. The scar from that surgery was \napproximately a 5 cm Pfannenstiel -Kerr incision \nlocated just above the pubic symphysis. The onset of \ncyclic scar pain began roughly a year after that surgical \nprocedure and progressively intensified, while blood \nstaining at the scar synchronized with menstrual cycles \nappeared around a year late r. She did not report any \nother significant medical or surgical history. \n Upon examination, the patient had stable vital signs. \nAbdominal inspection showed a well-healed transverse \nsuprapubic scar. At the center of this scar was a nodular \nswelling approximately 3×3 cm in size, with a slight \nbluish-brown discoloration of the ove rlying skin. A \ntrace of blood was observed oozing from a pinpoint \narea in the scar during the second day of her \nmenstruation ( Figure 1). Palpation revealed a firm, \ntender nodule fixed to the abdominal wall at the scar \nsite; no herniation was present, and t he remaining \nabdomen was soft and non -tender. The pelvic \nexamination was normal, showing a typical sized \nanteverted uterus without any adnexal masses or \ntenderness. \nUltrasonography of the abdominal wall revealed an \nill-defined, irregular heterogeneously hypoechoic \nlesion about 3 cm in size located in the subcutaneous \ntissue of the abdominal wall, adjacent to the rectus \nmuscle, with internal vascularity noted on Dopple r \nimaging (indicative of an endometriotic implant) \n(Figure 2). MRI of the abdomen and pelvis was \nperformed for improved anatomical visualization that \nshowed a well -defined solid mass measuring \n4.4×3.5×2.7 cm in the subcutaneous area of the right \nlower abdo minal wall (at the site of the tubectomy \nscar). The lesion appeared isointense on T1 -weighted \nimages and hypointense on T2 -weighted images, with \nno signs of deeper extension beyond the anterior rectus \nsheath or into the peritoneal cavity ( Figure 3). These \nimaging characteristics were compatible with a \nsubcutaneous endometriosis (endometrioma) localized \nto the abdominal wall. The MRI findings, along with \nthe lesion’s location, strongly suggested scar \nendometriosis. \nConsidering the patient's history and the clinical and \nradiological results, scar endometriosis was diagnosed. \nIt was decided to proceed with surgical intervention. \nThe patient underwent wide local excision of the \nabdominal wall endometriotic mass under re gional \nanesthesia. A curved incision was made around the \nexisting scar, encompassing the entire palpable nodule \nalong with a margin of healthy tissue. During the \nsurgery, a 4×4 cm firm mass was dissected from the \nsurrounding subcutaneous tissues and excise d en bloc \ndown to the level of the rectus sheath. The lesion was \ntightly adherent to the rectus fascia, necessitating the \nremoval of a portion of the sheath without \nfragmentation to ensure clear margins. Following \nexcision, the cut surface of the mass show ed areas of \nfibrosis containing “chocolate -colored” fluid and old \nblood debris, including a few bluish punctate spots \nwithin the tissue - a gross morphology consistent with \nan endometriotic tumor (Figure 4). The abdominal wall \ndefect was repaired with interrupted 1-0 polypropylene \n(Prolene) sutures to close the fascial layer, and the skin \nwas sutured with nylon. The postoperative course was \nuneventful, and the patient made a good recovery. \nHistopathological analysis of the excised tissue \nconfirmed the diagnosis. On gross examination, the \nspecimen was a fibro fatty nodule exhibiting cystic \ndegeneration filled with old blood. Microscopic \nexamination using hematoxylin and eosin staining \nrevealed endometrial glandular epithelium organizing \ninto glands and cystic structures, surrounded by \nendometrial stromal cells embedded within fibro \ncollagenous scar tissue and adjacent muscle. Evidence \nof hemorrhage and a sinus tract extending to the skin \nsurface, with surrounding granulation tissue, correlated \nwith the clinically observed bleeding sinus ( Figure 5). \nThese findings established the diagnosis of \nendometriosis in the scar. The patient was discharged \non postoperative day 2 with stable vital signs and a \nclean surgical wound. She received instructions for \nroutine postoperative care, including daily dressi ng \nchanges, suture inspection, and medications such as \noral analgesics and antibiotics (Amoxicillin-clavulanic \nacid 625 mg twice daily for 5 days). Act ivity \nrestrictions included avoiding heavy lifting and \nstrenuous abdominal exercises for 4 -6 weeks, with \nsuture removal on day 7. A clinical review was \nscheduled for 1 and 3 months postoperatively. Since \nthe lesion was entirely excised and the patient wanted \nto preserve fertility, no hormonal therapy was started. \nShe was informed about signs of recurrence and \ninstructed to report any pain, swelling, or bleeding \nfrom the scar. \n \n\n805 Cyclical Bleeding from an Abdominal Wall Scar \n      Volume 10, October 2025       Journal of Obstetrics, Gynecology and Cancer Research \n \nFigure 1. Clinical image- Abdominal scar examination \n \n \n \nFigure 2. Ultrasound image showing a heterogeneously hypoechoic, ill-defined lesion in the subcutaneous plane, with internal \nvascularity (color Doppler). The lesion is located at the site of the surgical scar and abuts the rectus abdominis muscle \n \n \n \n \n \n \n \n \n \n \nFigure 3. Pelvic MRI showing an anterior abdominal wall lesion (pink arrows) at the site of the prior Pfannenstiel incision. \nOn T1-Weighted (T1W) images (top left), the lesion appears isointense; On T2 -weighted (T2W) images (top right), the \nlesion appears hypointense characteristic of endometriotic tissue with fibrotic and hemorrhagic components. No extension \ninto the peritoneal cavity or underlying muscle was noted. \n\n\nGiddaluru Bhavya Muralikrishna, et al. 806 \n      Volume 10, October 2025       Journal of Obstetrics, Gynecology and Cancer Research \n \nFigure 4. Intraoperative Image- Excised Abdominal Wall Endometriotic Mass. The cut surface reveals fibrotic areas \ninterspersed with brownish, chocolate-colored hemorrhagic fluid and cystic spaces- characteristic of endometriotic tissue. \n \n \n \nFigure 5. Histopathological examination of the excised scar nodule reveals endometrial glands (indicated by the arrow) \nsurrounded by endometrial stroma and a sinus tract along with granulation tissue development underneath.  \n \n3. Discussion \nScar endometriosis is a rare complication of obstetric \nor gynecologic surgery, with the most frequently \naffected area being Cesarean section scars (6). The \nestimated incidence of endometriosis in a cesarean scar \nrange from 0.2% to 0.8%, although some extensive \nreviews suggest a broader range of approximately \n0.03% to 0.45% (1,6). This condition often remains \nundiagnosed due to its infrequency and ability to \nimitate other post-surgical lesions. In the present case, \nthe patient’s history of undergoing tubal ligation (mini \nlaparotomy) likely triggered the introduction of \nendometrial tissue into the abdominal wall. Although \ncesarean delivery is the typical r isk factor, there have \nalso been instances of scar endometriosis following \nprocedures like abdominal tubal sterilization, \nhysterotomy for abortion, myomectomy, or even \nlaparoscopy, essentially any surgical procedure that \ncould implant endometrial cells int o a wound. Not \nevery surgical contamination results in endometriosis, \nindicating that other factors (such as individual \nsusceptibility or immune and hormonal influences) are \ninvolved in whether implanted cells will grow. Some \nevidence suggests a genetic te ndency towards \n\n\n807 Cyclical Bleeding from an Abdominal Wall Scar \n      Volume 10, October 2025       Journal of Obstetrics, Gynecology and Cancer Research \ndeveloping endometriosis at ectopic sites, but the \nprevailing theory for the pathogenesis of scar \nendometriosis is direct implantation during surgery \ncombined with subsequent hormonal stimulation of the \nimplants (7,8). Classic theories pertaining to the \npathogenesis of pelvic endometriosis  such as \nSampson’s retrograde menstruation and coelomic \nmetaplasia are less applicable to scar endometriosis, \nexcept in cases where endometrial tissue may access a \nscar through tubal reflux (as was previously \nhypothesized regarding endometriosis following tubal \nligation). In our patient, it appears that endometrial \ntissue from the uterine cavity or fallopian tubes was \nunintentionally deposited into the abdominal wall \nincision during the tubal ligation, remaining dormant \nuntil factors such as estrogen -progesterone cycles \nencouraged its growth.  \nPatients with scar endometriosis usually present with \na palpable mass at or close to the scar and pain often \ncorresponding with menstrual cycle. A review of 198 \ncases of cesarean scar endometriosis indicated that \napproximately 87% of patients experienced c yclical \npain associated with menstruation, while a smaller \npercentage reported continuous or non -cyclical pain \n(5). The duration from the initial surgery to the onset \nof symptoms can vary widely, averaging about 2 to 5 \nyears (3). Interestingly, our patient  experienced the \nsymptoms relatively sooner (within 1 to 2 years), \npossibly due to the smaller incision and the closer \nproximity of endometrial tissue to the skin surface in a \ntubectomy scar. Visible bleeding from the scar, as \nobserved in our patient, is u ncommon but has been \ndocumented when endometriotic lesions involve the \nepidermis. This striking symptom can aid in the \ndiagnosis, as scar endometriosis is more frequently \nmistaken with other conditions. The differential \ndiagnosis for an abdominal wall mass in a woman with \nprior pelvic surgery includes incisional hernia, surgical \nsite hematoma or abscess, suture granuloma, desmoid \ntumor, lipoma, or metastatic tumor implant (9). \nRecognizing the cyclical nature of the symptoms is \ncrucial for differentiating scar endometriosis from \nother conditions. In the present case, the occurrence of \nmenstrual bleeding from the scar was a clear indicator \nsuggesting endometriosis and helped pre vent \nconfusion in diagnosis. \nThe assessment of suspected scar endometriosis \nrequires an integration of patient history and \nexamination with imaging studies and tissue analysis. \nUltrasound serves as a valuable initial imaging \ntechnique: a scar endometrioma usually presents as a \nsolid o r mixed solid -cystic mass that appears \nhypoechoic compared to fat and may include internal \nechogenic spots or fluid -filled areas resulting from \nbleeding (10). Doppler ultrasound frequently reveals \ninternal blood flow. In our patient, a heterogeneous \nvascular mass within the subcutaneous layer was \nobserved in the ultrasound, which, considering the \nclinical context, was consistent with an endometriotic \nlesion. MR I can be particularly advantageous for \ndetailing the extent of the lesion and any nearby \nstructure involvement. On MRI, lesions of scar \nendometriosis typically exhibit signal patterns akin to \nhemorrhagic tissue- they can be isointense or slightly \nhyperintense on T1 -weighted images, with regions of \nhyperintensity if there is acute bleeding present and are \ngenerally hypointense on T2 -weighted images due to \ndense fibrosis and hemosiderin accumulation (3). In \nour patient, MRI confirmed that the endometriotic \nmass was restricted to the abdominal wall and there \nwas no infiltration into the peritoneal cavity, which was \nsignificant for surgical planning.  \n   While imaging outcomes can strongly indicate the \ndiagnosis, histopathology provides ultimate \nconfirmation. A preoperative core needle biopsy or \nFine-Needle Aspiration Cytology (FNAC) can reveal \nendometrial cells within the mass, though this is not \nalways requisite if the clinical picture is evident, and \nsome surgeons choose to avoid needle biopsy due to \nworries about potential tissue seeding along the tract. \nWhen conducted, FNAC  has demonstrated high \nsensitivity (close to 100% in certain studies) for \ndetecting scar endometriosis, showcasing clusters of \nendometrial glandular cells, stromal cells, and \nhemosiderin-loaded macrophages in cytological \npreparations (11). In one investigation, all cases of scar \nendometriosis undergoing FNAC were accurately \nidentified cytologically (12). In the current case, due to \nthe clear clinical cyclical bleeding and the correlation \nwith imaging, we advanced directly to excisional \nsurgery without FNAC. Definitive histological analysis \nof the excised tissue showed the presence o f \nendometrial glands and stroma, which is diagnostic for \nendometriosis. Histology typically reveals surrounding \ninflammation, fibrosis, and pigment -laden \nmacrophages resulting from recurrent bleeding (3). It \nis crucial that both endometrial glands and stroma are \nfound in the sample to affirm the diagnosis; otherwise, \nthe findings could indicate other conditions (for \ninstance, isolated endosalpingiosis or a stromal \nnodule). \nSurgery is the main treatment for scar endometriosis. \nThe optimal approach is wide local excision of the \nlesion with clear margins, which offers the best chance \nof resolution. Medical treatment (like hormonal \nsuppression via oral contraceptives, progestins , \ndanazol, or GnRH analogues) has limited effectiveness \nin scar endometriosis - it may temporarily alleviate \nsymptoms but generally does not eliminate the lesion \n(12). In our patient, surgical removal of the lesion was \nsuccessful, as documented cases. A mar gin of at least \n1 cm of healthy tissue surrounding the lesion is often \nadvised to ensure complete excision. If the \nendometrioma affects the fascia or muscles, those parts \nshould be surgically removed; large defects might \nrequire mesh repair or tissue flap reconstruction in \ncertain scenarios. In this case, the mass was excised \ncompletely along with part of the rectus sheath, and the \ndefect was small enough to be primarily closed. After \nthorough excision, the recurrence of scar endometriosis \n\nGiddaluru Bhavya Muralikrishna, et al. 808 \n      Volume 10, October 2025       Journal of Obstetrics, Gynecology and Cancer Research \nis extremely uncommon. Research has indicated a low \nrate of recurrence when wide excision with clear \nmargins is accomplished (1). On the other hand, \nincomplete resection or spillage of endometrial tissue \nduring the operation can cause either persistence or \nrecurrence of the disease. Postoperative adjunct \ntherapy is not typically necessary, but some healthcare \nproviders choose to initiate hormonal suppression (like \na course of GnRH agonists or ongoing oral \ncontraceptives) after surgery to reduce the risk of \nmicroscopic foci returning, particularly if the resection \nmargins were narrow (12). In our patient, due to the \nclear margins and her wish for future pregnancies, no \nmedical suppression was administered, and she \nremained symptom -free. A developing non -surgical \napproach for treating abdominal wall endometriosis in \nspecific cases is High-Intensity Focused Ultrasound \n(HIFU) ablation, which can thermally eliminate the \nectopic tissue without causing an incision (9). \nNevertheless, surgical intervention remains the  \ndefinitive and most effective treatment for accessible \nlesions. \n \n4. Conclusion \nThis case report emphasizes that the combination of \ncyclical pain, a nodular mass located in or near a scar, \nand a correlation with menstrual cycles strongly \nindicates scar endometriosis. An accurate diagnosis \nrequires a thorough medical history and physic al \nexamination, along with appropriate imaging and \nconfirmation through histopathology. The definitive \nsolution involves the surgical removal of the lesion \nwith clear margins, which not only relieves symptoms \nbut also prevents recurrence.  \n \n5. Declarations \nAcknowledgments \nThe authors would like to thank the Department of \nObstetrics and Gynecology at SRM Medical College \nHospital and Research Centre for their support in \nmanaging the patient and facilitating the preparation of \nthis manuscript. We also acknowledge the patient f or \nproviding informed consent and permitting the \npublication of clinical details and images. \n \nEthical Considerations \nInformed written consent was obtained from the \npatient for the publication of this case report and any \naccompanying images. Ethical approval was not \nrequired for this single -patient case report as per \ninstitutional guidelines, as no experimental \nintervention was involved. \n \nAuthors' Contributions \nBhavya Giddaluru contributed to the \nconceptualization, clinical management, manuscript \ndrafting, and image documentation. Karthiga Prabhu \nperformed clinical supervision, surgical intervention, \nand manuscript revision.  \n \nConflict of Interest \nThe authors declare no conflict of interest regarding \nthe publication of this case report. \n \nFund or Financial Support \nThis study received no external financial support.  \n \n \n1. Sharmila V, Kamatham V, Shankaralingappa A. \nAbdominal scar endometriosis: A case report \nand review of literature. Indian J Pathol \nMicrobiol. 2023 ;66(4):871-3. \n[DOI:10.4103/ijpm.ijpm_460_22] \n2. Bulletti C, Coccia ME, Battistoni S, Borini A. \nEndometriosis and infertility. J Assist Reprod \nGenet. 2010;27(8):441 –7. \n[DOI:10.1007/s10815-010-9436-1] \n3. Al Shenawi H, Al Shenawi N, Al Mousa NA, Al \nAbbas LA, Al Zayer NM, Alqhtani MM, et al. A \nTypical Presentation of Cesarean Section Scar \nEndometriosis: A Case Report. Cureus. 2023 ; \n15(12):e49884. [DOI:10.7759/cureus.49884] \n4. Kocher MR, Hardie A, Schaefer A, McLaren T, \nKovacs MD. Cesarean -Section Scar \nEndometrioma: A Case Report and Review of \nthe Literature. J Radiol Case Rep . \n2017;11(12):16–26. \n[DOI:10.3941/jrcr.v11i12.3178] \n5. Zhang P, Sun Y, Zhang C, Yang Y, Zhang L, \nWang N, et al. Cesarean scar endometriosis: \npresentation of 198 cases and literature review. \nBMC Womens Health. 2019;19(1):14. \n[DOI:10.1186/s12905-019-0711-8] \n6. Vagholkar K, Vagholkar S. Abdominal Wall \nEndometrioma: A Diagnostic Enigma —A Case \nReport and Review of the Literature. Case Rep \nObstet Gynecol. 201 ;2019: 6831545. \n[DOI:10.1155/2019/6831545] \n7. Poudel D, Acharya K, Dahal S, Adhikari A. A \ncase of scar endometriosis in cesarean scar: A \nReferences \n\n809 Cyclical Bleeding from an Abdominal Wall Scar \n      Volume 10, October 2025       Journal of Obstetrics, Gynecology and Cancer Research \nrare case report. Int J Surg Case Rep. \n2023;102:107852. \n[DOI:10.1016/j.ijscr.2022.107852] \n8. 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Imaging \nin Endometriosis and Adenomyosis. Clin Obstet \nGynecol. 2017;60(1):27 –37. \n[DOI:10.1097/grf.0000000000000265] \n \n \n \n \nHow to Cite This Article:  \nMuralikrishna, G.B., Prabhu, K. Cyclical Bleeding from an Abdominal Wall Scar: A Clinical Case of Scar \nEndometriosis. J Obstet Gynecol Cancer Res. 2025;10(10):803-9. \nDownload citation:                             RIS | EndNote | Mendeley |BibTeX |","source_license":"CC0","license_restricted":false}