{"paper_id":"6168cb5b-4894-4c87-9b59-2fe450c1ff69","body_text":"Citation: Al-Jefout M. The Novel Use of Subdermal Implant Containing Etonogestrel Progestogen (ImplanonR) for the Treatment of a Difficult and Recurrent \nCase of Abdominal Wall Endometriosis, a Case Report. J Clin Med Case Reports. 2013;1(1): 2.\nJ Clin Med Case Reports\nApril 2013 Issue:1, Vol.:1\n© All rights are reserved by MoamarAl-Jefout.\nThe Novel Use of Subdermal \nImplant Containing Etonogestrel \nProgestogen (ImplanonR) for \nthe Treatment of a Difficult and \nRecurrent Case of Abdominal \nWall Endometriosis, a Case \nReport\nKeywords: Abdominal wall endometriosis; subdermal implant \n(Implanon); pain; Treatment.\nAbstract\nBackground: Abdominal wall endometriosis is to be found to \nincrease due to the rapid increase of caesarean section rates.\nThe Case: The author report a case of a 44 year old multiparous \nwoman diagnosed with recurrent abdominal wall endometriosis \nafter cesarean section few years ago for which she underwent wide \nsurgical excision and was treated medically with GnRH agonists with \nno long term improvement. The case was successfully treated with a \nnovel use of subdermal implant containing etonogestrel progestogen \n(ImplanonR) with the addition of oral progestogen. After one year \nfollow up; the patient is pain free and the mass has substantially \nreduced in size. The patient had some troubles with occasional \nbreakthrough bleeding episodes which were treated in addition to \nsome weight gain.\nConclusion: The use of subdermal implants can be used as an \noption for the treatment of abdominal wall endometriosis. However, \nmore studies on more cases are needed.\nIntroduction\nEndometriosis is an inflammatory condition characterized by \nlesions of endometrial-like tissue outside of the uterus which may \nbe associated with pelvic pain and infertility [ 1]. Clinical symptoms \ninclude dysmenorrhea, dyspareunia, infertility, painful defecation \nor cyclic urinary symptoms. Extra pelvic endometriosis is relatively \na rare condition and mainly found after gynecological surgery \nsuch as hysterectomy, caesarean section, laparoscopic procedures, \nepisiotomy and very rarely amniocentesis[2]. However, abdominal \nwall endometriosis is to be found to increase due to the rapid increase \nof caesarean section rates.\nThe prevalence of abdominal wall endometriosis is reported to be \naround 0.03%-1.08% in women with previous history of gynecological \nor obstetrical surgery [3]. In one study the time interval between the \nsurgery and the mass presentation was 3,6 years after the surgery [4]. \nHowever, there are some reports in the literature about spontaneous \nabdominal wall endometriosis with no previous history of any \nscars [4]. The pathogenesis of abdominal wall endometriosis can be \nexplained by two possible mechanisms; either form direct implants \nof the endometrial implants during the procedure with proliferation \nunder hormonal influence or from local metaplasia of the surrounding \ntissue to form endometrioma. The classical symptoms of abdominal \nwall endometriosis are a painful swelling and cyclic pains related \nto the menstrual period, but all of these symptoms are not always \nassociated. Ultrasound in combination of clinical finding can be \nused to diagnose abdominal wall endometriosis [ 5]. The differential \ndiagnosis is made with other lesions, such as hernias, post-operative \nventral hernias, hematomas, granulomas, abscesses, and tumours [6] \nand this differential diagnosis may be difficult in most cases [7]. The \nstandard way to treat these lesions is a wide excision of the mass with a \n1 cm safe margin with or without patch grafting[8]. In recurrent cases \na combination of surgical re-excision and postoperative adjuvant \nmedical therapy is recommended [9].\nImplanon (Organon International), is a single-rod long acting \nreversible hormonal contraceptive subdermal implant that is inserted \njust under the skin of a woman’s upper arm. The 4  cm by 2  mm \nImplanon rod contains 68 milligrams of Etonogestrel which is released \nover a three year period. Peak serum etonogestrel concentrations \nhave been found to reach 781–894 pg/mL in the first few weeks, \ngradually decreasing to 192–261 pg/mL after 1 year, 154–194 pg/mL \nafter 2 years, and 156–177 pg/mL after 3 years, maintaining ovulation \nsuppression and contraceptive efficacy.\nThe case: a 39year old (at the time of first consultation)\nmultiparousJordanian woman. She underwent caesarean sectionthree \nyears prior to first consultation. The patient attended my outpatient \nclinic complaining of cyclical abdominal wall pains associated with \nmenstrual flow. During abdominal examination a well-defined mass \nwas palpable 5 cm below the umbilicus 3 cm lateral to midline, \nmeasuring on 12 cm by 10cm. The mass was not tender and not \nmobile involving the sheath and underlying muscle. On trans-\nabdominal ultrasound scan a hypoechogenic mass was confirmed \nmeasuring 12 by 10 cm and 3 cm depth. The patient gave history of 2 \nunsuccessful attempts of wide excision of the mass by surgeons with \npositive histopathology showing clear evidence of endometriosis. \nThe pathology reports revealed microscopic finding consisting of \nendometrial glands and stroma scattered in fibro-collagenous scar \ntissues. After one year of the last surgical excision the mass reoccurred \nand the patient received two courses of GnRH agonist treatment for \nsix month duration in each time with nosustainable improvements in \nthe size or in pain symptoms.\nMoamar Al-Jefout*\nDepartment of Obstetrics & Gynaecology, Mutah Medical Faculty, \nMutah University, Jordan\nAddress for Correspondence\nMoamar Al-Jefout, Department of Obstetrics & Gynaecology, Mutah \nMedical Faculty, Mutah University, Jordan; E-mail:  drmoamar@yahoo.\nco.uk\nSubmission: 07 March 2013\nAccepted: 18 April 2013\nPublished: 19 April 2013\nJournal of\nClinical & Medical \nCase Reports\nCase ReportOpen Access\n\nCitation: Al-Jefout M. The Novel Use of Subdermal Implant Containing Etonogestrel Progestogen (ImplanonR) for the Treatment of a Difficult and \nRecurrent Case of Abdominal Wall Endometriosis, a Case Report. J Clin Med Case Reports. 2013;1(1): 2.\nJ Clin Med Case Reports 1(1): 2 (2013) Page - 02\nInsertion of subdermal implant (Implanon ®) was decided and \nperformed after written consent of patient for it use as a novel \noption for the treatment of her condition. After 2 month pain \nsymptoms were gradually decreased and finally were subsided. \nThe sizeof the mass slowly decreased and was evident on monthly \nclinical examinations and trans-abdominal ultrasound scans. After \nthree months a substantial reduction in the size was noticed and \npain symptoms completely vanished. A troublesome breakthrough \nbleeding occurred few months after the insertion and could only be \nmanaged by adding continuous oral progestogen (Provera 5 mg bd).\nIn addition, a slight increase in weight was noticed and was managed \nby changing life style. The patient had a DXA(Dual X ray Absorba-\nmetry) scan to exclude any side effects of long standing progestin \ntherapy on her bone density; the scan was normal. After 3 years of \nfollow up the mass is almost not palpable and the scan shows a small \n2 by 3 cm endometrioma just beneath the rectus sheath very attached \nto the lower borders of the sheath. Because of the improvement in her \nquality of life (QoL) and decreasing mass size, another implant was \ninserted after three years which is in situ for the last 2 years.She is still \non taking the provera 5 mg once daily and she is very satisfied with \nher management.\nDiscussion\nThis case report suggests that the use of subdermal etonorgestrel \nimplant may be an option for the treatment of difficult and recurrent \ncases of abdominal wall endometriosis refractory to standard surgical \nexcision. In this case the patient received two progestogens one \nsubdermal and later another oral progestogen. In my opinion the \nmain therapeutic effect came from the implant as the mass started to \nshrink before starting the oral progestogens. Up to my knowledge this \nis the first case where such modality of treatment was used. However, \nit should be remembered; that the current gold standard of first line \ntreatment for abdominal wall endometriosis should be a wide surgical \nexcision and the proposed modality of treatment should be reserved \nfor recurrent cases.\nThese cases usually present to surgeons, however, they might \nbe underdiagnosed or missed [ 10] and a referral to a gynecologist \nis recommended in every case [ 11]. Moreover, the diagnosis of \nabdominal wall endometriosis should be included in the differential \ndiagnosis of any abdominal wall mass after abdominal surgery [12].\nEtonogestrel subdermal implants have been used as an additional \ntreatment option in women with symptoms related to pelvic \nendometriosis [13,14]. These implants deliver a systematic and \nrelatively steady dose of progestogens that have a therapeutic effect \non the ectopic lesions either on their own or on combination with \nother progestogens.\nReferences\n1. Giudice LC, Evers JLH, Healy DL (2012) Endometriosis: Science and \nPractice. Wiley-Blackwell, USA.\n2. Hughes ML, Bartholomew D, Paluzzi M (1997) Abdominal wall endometriosis \nafter amniocentesis. A case report. J Reprod Med 42: 597-599.\n3. Eljuga D, Klaric P, Bolanca I, Grbavac I, Kuna K (2012) Abdominal wall \nendometriosis: case report. Acta Clin Croat 51: 261-263.\n4. Kang J, BaekJH, Lee WS, Cho TH, Lee JN, et al. (2013) Clinical manifestations \nof abdominal wall endometriosis: a single center experience. Arch Gynecol \nObstet 287: 301-305.\n5. Alexiadis G, Lambropoulou M, Deftereos S, Giatromanolaki A, Sivridis E, et \nal. (2001) Abdominal wall endometriosis--ultrasound research: a diagnostic \nproblem. Clin Exp Obstet Gynecol 28: 121-122.\n6. Rulli F, Pacella A (1998) Endometriosis of the abdominal wall. Acta Biomed \nAteneo Parmense 69: 139-143.\n7. Dumitrescu AS, Herold T (2011) Endometriosis of the abdominal wall: a \ndifficult differential diagnosis. Rofo 183: 861-864.\n8. Cheng NH, Zhu L, Lang JH, Liu ZF, Sun DW, et al. (2006) Repair of abdominal \nwall defect after resection of abdominal wall endometriosis. Zhonghua Yi Xue \nZa Zhi 86: 1919-1921.\n9. Ding Y, Zhu J (2013) A retrospective review of abdominal wall endometriosis \nin Shanghai, China. Int J Gynaecol Obstet 121: 41-44.\n10. Nirula R, Greaney GC (2000) Incisional endometriosis: an underappreciated \ndiagnosis in general surgery. J Am Coll Surg 190: 404-407.\n11. Singh KK, Lessells AM, Adam DJ, Jordan C, Miles WF, et al. (1995) \nPresentation of endometriosis to general surgeons: A 10-year experience. Br \nJ Surg 82: 1349-1351.\n12. Kocakusak A, Arpinar E, Arikan S, Demirbag N, Tarlaci A, et al. (2005) \nAbdominal Wall Endometriosis: A Diagnostic Dilemma for Surgeons. Med \nPrinc Pract 14: 434-437.\n13. Al-Jefout M, Palmer J, Fraser IS (2007) Simultaneous use of a levonorgestrel \nintrauterine system and an etonogestrelsubdermal implant for debilitating \nadolescent endometriosis. Aust N Z J Obstet Gynaecol 47: 247-249. \n14. Yisa SB, Okenwa AA, Husemeyer RP (2005) Treatment of pelvic \nendometriosis with etonogestrel subdermal implant (Implanon). J Fam Plann \nReprod Health Care 31: 67-70.\n15. Francica G (2012) Reliable clinical and sonographic findings in the diagnosis \nof abdominal wall endometriosis near cesarean section scar. World J Radiol \n4: 135-140.\n16. Hensen JH, Van Breda Vriesman AC, PuylaertJB (2006) Abdominal wall \nendometriosis: clinical presentation and imaging features with emphasis on \nsonography. AJR Am J Roentgenol 186: 616-620.\n17. Zhao R, Wang XJ, Song KX, Zhu L, Li B (2012) Mini-abdominoplasty \ncombined with mesh used for abdominal wall endometriosis. Chin Med J \n(Engl) 125: 1614-1617.\nISSN: 2332-4120","source_license":"CC0","license_restricted":false}