{"paper_id":"83f66ebf-09ba-412c-84b6-08b3782d2931","body_text":"Abstract\nVulvar endometriosis can occur after surgery or trauma and cause dyspareunia. A 30-year-old woman presented with orificial dyspareunia lasting for 5 months. Her history was marked by a vaginal birth without perineal injury and the removal of a cyst from the left Bartholin’s gland. On examination, we observed a selectively painful, superficial and retractile lesion, 5 mm in diameter at the junction of the hymen at some distance from the bartholinitis scar. Endometriosis was suspected due to the exacerbation of pain during menses. The surgery consisted of excision of the hymenal area of the painful lesion. Pathological examination confirmed the presence of endometrial tissue. The painful symptoms resolved and no additional treatment was administered. Any vulvar lesion, regardless of its appearance and location, can be related to endometriosis. Surgical resection is recommended to relieve the symptoms and provide histological proof.\nBackground\nDyspareunia occurs in 46% of sexually active women1 and is mainly due to endometriosis,2 provoked vestibulodynia, vaginismus, vaginitis, urethritis3 and dermatoses.4 Endometriosis is characterised by ectopic growth of endometrial tissue outside the uterine cavity5 and can cause dyspareunia when it affects the perineum and the vulva.2 Vulvar endometrial lesions usually occur after surgery6 or trauma7 but rarely spontaneously.8–10 The most common sites are episiotomy scars,6 11 Bartholin’s gland12 and more rarely labia majora2 or labia minora.13\nThe authors report a case of a spontaneously developed hymeneal endometriosis responsible for dyspareunia.\nCase presentation\nA 30-year-old woman, gravida 1 para 1, presented with orificial dyspareunia lasting for 5 months. Her history was marked by a vaginal birth without perineal injury 18 months ago and the removal of a 5 cm cyst from the left Bartholin’s gland 10 months previously. Anatomopathological examination confirmed the diagnosis of chronic bartholinitis and the postoperative course and healing were favourable. Painful symptoms appeared 5 months after the operation, and were predominant during perimenstrual periods. The patient reported no other symptoms such as dysuria, pelvic pain, dysmenorrhoea or dyschezia. On examination, the bartholinitis scar was observed at the 5 o'clock position. There was also a selectively painful, superficial and retractile lesion, 5 mm in diameter, at the 1 o'clock position at the hymen junction (figure 1). The rest of the examination was normal. Endometriosis was suspected due to the exacerbation of pain during menses.\nSurgery consisted of a rhomboid excision of the hymenal area of the painful lesion and the underlying fibrous tissue. Pathological examination confirmed the presence of endometrial tissue (figure 2). The postoperative course was favourable with disappearance of painful symptoms. No additional treatment was necessary.\nDiscussion\nSpontaneous perineal location of endometriosis is unusual and may be explained by the lymphovascular dissemination theory.8 14 This is the first case of hymeneal location of endometriosis without trauma. Symptoms are often atypical and include vulvar pain, pruritus or dyspareunia.2 On examination, an ill-defined dark red, brown or blue-black cystic papule or nodule8 or ulcer13 can be found. In our case, the lesion was 5 mm in diameter and very superficial with a retractile appearance in an area free of any scar. However, we cannot completely rule out the possibility that this endometriotic lesion was grafted onto a scar made accidentally during the surgery for bartholinitis. Therefore, the only diagnostic criterion to suggest endometriosis was the cyclic pattern related to menses.7 Final diagnosis was concluded by histological analysis, which showed endometrial glandular structures surrounded by a cellular stroma, and the disappearance of symptoms after surgery.\nIn summary, our case highlights that any vulvar lesion, regardless of its appearance and location, can be related to endometriosis. Surgical resection is recommended to relieve symptoms and provide histological proof.\nLearning points.\nAny vulvar lesion, regardless of its appearance and location, can be related to endometriosis.\nThe only diagnostic criterion to suggest endometriosis may be the cyclic pattern related to menses.\nSurgical resection is recommended to relieve symptoms and provide histological proof.\nFootnotes\nCompeting interests: None.\nPatient consent: Obtained.\nProvenance and peer review: Not commissioned; externally peer reviewed.\nReferences\n- 1.Jamieson DJ, Steege JF. 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