{"paper_id":"a53b23df-1168-4a95-bea7-9c465624faf9","body_text":"Open Access, Volume 3\nCase Report\nwww.jclinmedimages.org\nReceived: Mar 15, 2023\nAccepted: Apr 03, 2023\nPublished: Apr 10, 2023\nArchived: www.jclinmedimages.org\nCopyright: © Azhar A (2023).\n*Corresponding Author: Afshan Azhar\nUniversity Maternity Hospital Limerick, Ennis \nRoad, Limerick, Ireland. \nEmail: afshan.azhar0908@gmail.com\nDecidual cast severe pelvic pain mimics acute\nappendicitis in an adolescent girl\nGaboura A1; Azhar A2*; Abushara Y1; Munawar G2; Dunn E3\n1Registrar of Ob. Gyn., University Maternity Hospital Limerick, Ennis Road, Limerick, Ireland.\n2Senior House Officer of Ob. Gyn., University Maternity Hospital Limerick, Ennis Road, Limerick, Ireland.\n3Associate Professor and Consultant Obstetrician and Gynaecologist, Wexford General Hospital, Newtown Road, Wexford, Ireland. \nAbstract\nBackground: Decidual Cast is a reaction to hormonal medications re-\nsulting in the formation of a cast taking the shape of the uterine cavity. \nIts incidence is unknown; however, it is usually associated with heavy \nmenstrual bleeding, dysmenorrhoea and pelvic pain.\nCase report: We present a case of an adolescent girl who was admit-\nted with severe right side abdominal pain mimicking acute appendicitis. \nShe was brought to the theatre for laparoscopic appendectomy, which \nwas normal. She passed a decidual cast through her vagina the follow-\ning day.\nDiscussion: There are many theories behind the formation of the \ndecidual casts. However, the most acceptable theory correlated it with \nhormonal contraception.\nKeywords: Decidual cast; Contraceptive pills; Adolescent.\nIntroduction\nIn most reported cases, the decidual cast is an iatrogenic pa-\nthology related to hormonal reactions during a woman’s men -\nstrual cycle. In each menstrual cycle, the endometrium natu -\nrally sheds down and passes through the vagina, but rarely the \nendometrium tissue becomes thickened and retains the shape \nof the cavity, forming a decidual cast. The cast can be painful \nto pass during menstruation causing severe pain [1]. Heavy \nmenstrual bleeding is highly encountered in the adolescent age \ngroup reaching nearly 18% of teenagers [2]. The differential di-\nagnosis of the decidual cast formation can range from benign \nconditions like; miscarriages, ectopic pregnancy, uterine polyps, \nmyomas or foreign bodies to more serious pathologies like sar-\ncoma or carcinoma [3-5,15,16].\nCase report\nHere we present a 14-year-old girl who reported to the \nemergency department complaining of severe pelvic pain, \nmainly on the right side. She had a history of heavy menstrual \nbleeding for the last four months, for which her doctor advised \nher to use combined oral contraception. Physical examination \nrevealed a normal development for her age. Laboratory reports \nwere standard except for the high WBCs count of 21.5 x 103  \nand the C reactive protein of 38 IU. Ultrasound findings showed \nnormal sized uterus with an endometrial thickness of 38 mm, \nmainly at the upper part of her uterus.\nShe was seen by a surgical consultant who suspected acute \nappendicitis and performed a diagnostic laparoscopy. On lap -\naroscopy, the appendix was normal, and few endometriotic \nspots were found in the pelvis. However, she had a normal uter-\nus. The next day, the patient had severe spasmodic pain in the \nlower abdomen and noiced a lump coming through her vagina. \nSubsequently, she passed lump measuring 3 x 5 x 6 cm (Figures \n1 & 2).\nAn ultrasound scanning showed an endometrial thickness of \n9.9 mm (Normal). The lump was sent for a histopathology ex -\namination which revealed necrotic and inflamed decidualized \nstroma and decidual cast.\n\nwww.jclinmedimages.org       Page 2\nCitation: Gaboura A, Azhar A, Abushara Y , Munawar G, Dunn E. Decidual cast severe pelvic pain mimics acute appendicitis \nin an adolescent girl. Open J Clin Med Images. 2023; 3(1): 1105.\nFigure 1: Shows the decidual cast measuring 3 X 5 X 6 cms.\nFigure 2: Shows the hollow cavity of the decidual cast of an ado -\nlescent girl.\nFour months later, the patient was brought for a follow-up \nhysteroscopy, which showed a normal uterine cavity. Endo -\nmetrial sampling was done, and histopathological examina -\ntion revealed normal secretory phase endometrium. Mirena \nIntrauterine System was inserted for menorrhagia instead of \nthe Yasmin pills (oral combined pills). The patient was followed \nup again after four months and was completely asymptomatic. \nUltrasound scan showed normal endometrium of 8.7 mm. She \nwas then discharged to her GP’s care.\nDiscussion\nIn most cases, the aetiology of the decidual cast is unknown, \nand it involves the passage of endometrial tissue with associ -\nated pelvic pain [3,6,7]. Decidual cast / membranous dysmenor-\nrhea have been in the literature since the second half of the 20th \ncentury [8]. The detachment of the cast occurs spontaneously, \nfollowed by its passage through the intact cervix to the vagina \n[8,9].\nAs we stated above, there are some theories explaining the \noccurrence of the decidual cast. Asch and Greenblatt assumed \nthat the decidual cast occurs due to overexposure to hormonal \nmedications (Estrogen & Progesterone). This result in heterog -\nenous thickened endometrium and cast formation [10,11,17]. \nDepo-Medroxy Progesterone Acetate (DMPA) directly cor -\nrelates with decidual cast formation [18]. On the other side, \nGreenblatt et al., has also believed that an element of infection \nleads to the formation of the decidual cast [10,12]. It is believed \nthat it is more related to using exogenous progesterone rather \nthan estrogen [13].\nSome authors also think that aetiology can be associated \nwith prostaglandin production [14,10]. Rabirneson et al. be -\nlieved that the membranous dysmenorrhea and decidual cast \nare due to cell-cell adhesion events mediated by the integrins \n[14]. The common pathologies in the adolescent age group are \nfibroepithelial polyps and sarcoma botryoides [15,16]. The ul -\ntrasound picture of the decidual cast usually appears as a het -\nerogenous mass mimicking an endometrial polyp [17]. In young \ngirls, it is more common to encounter fibroepithelial polyps and \nsarcoma botryoides [15,16].\nInvestigations can include\nPregnancy test, full blood count, C - reactive protein, ultra -\nsound scan and histology investigation [8,18]. The options for \nfollow-up include either stop using the same contraception \nmethod or continuing to use the same one. However, relapses \nhave rarely been reported [8,18]. The complications include se-\nvere pain [1,5], infection [1], heavy bleeding resulting in anemia \n[3,7,9] and blood transfusion [11].\nConclusion\nDecidual cast formation has no proved etiological factor. \nThere is no set protocol for investigation or management of \nit. On the other hand, there are no negative consequences to \nforming a decidual cast. The patient can continue using the \nsame method of contraception without causing problems.\nThe women need to be informed thoroughly about it.\nReferences\n1. Fukaura R, Ward A, Datta S. Delayed miscarriage inside an infect-\ned decidual cast: a rare complication of the Depo medroxypro -\n\nwww.jclinmedimages.org       Page 3\ngesterone acetate injection. BMJ Case Rep. 2021; 14: e238583. \n2. Houston AM, Abraham A, Huang Z, D’ Angelo LJ. Knowledge, at-\ntitudes, and consequences of menstrual health in urban adoles-\ncent females. J Pediatr Adolesc Gynecol. 2006; 19: 271-275.\n3. Maciel R, Rodrigues S, Inocêncio G, Saraiva J, Montalvão M. Dis-\nmenorreia membranosa: uma rara e desconhecida entidade. \nActa Obstet Ginecol Port. 2014; 894: 402-404.\n4. Sen Y , Cimbek EA, Ugras NS. Decidual cast after discontinuation \nof oral contraceptives use in a young girl. J Pediatr Adolesc Gy -\nnecol. 2013; 26: e127-129.\n5. Singh V, Talib N, Strickland J. Decidual cast in a girl receiving de-\npot medroxyprogesterone acetate--a case report. J Pediatr Ado-\nlesc Gynecol. 2007; 20: 191-194.\n6. Silveira DS, Jaenickie A, Hollanda ES, Valle RGA, Zimmermmann \nJB. Dismenorreia membranácea: ainda existe? Relato de Caso. \nRev HCPA. 2011; 31: 468-470.\n7. García VZ, Tabernero AL, Torres AA, Dávila FM, Haya J. Dismen-\norrea membranosa. Expulsión endometrial completa. Toko-Gin \nPract. 2010; 69: 182-184.\n8. Brehmer L, Engberg H. Membranös dysmenorré eller utstötning \nav decidualavgjutning [Membranous dysmenorrhea or passage \nof a decidual cast - forgotten phenomenon but not rare? Case \nreport and summary of the literature]. Lakartidningen. 2022; \n119: 22081.\n9. Oliveira PP , Eyng C, Zin RM, Menegassi J. Membranous dysmen-\norrhea - a forgotten disease. Rev Bras Ginecol Obstet. 2009; 31: \n305-310.\n10. Appelbaum H. Membranous dysmenorrhea: a complication of \ntreatment for endometriosis. Obstet Gynecol. 2010; 116: 488-\n490.\n11. Asch RH, Greenblatt RB. Primary and membranous dysmenor -\nrhea. South Med J. 1978; 71: 1247-1249, 1252.\n12. GREENBLATT RB, HAMMOND DO, CLARK SL. Membranous dys -\nmenorrhea: studies in etiology and treatment. Am J Obstet Gy -\nnecol. 1954; 68: 835-844.\n13. Perdomo CB, Jiménez PS, Fleites LA, Cruz GS, Vega BN, et al. Dis-\nmenorrea membranácea durante la menarquia. Rev Chil Obstet \nGinecol. 2016; 81: 135-137.\n14. Rabinerson D, Kaplan B, Fisch B, Braslavski D, Neri A. Membra -\nnous dysmenorrhea: the forgotten entity. Obstet Gynecol. 1995; \n85: 891-892.\n15. Malik MF, Adekola H, Porter W, Poulik JM. Passage of decidual \ncast following poor compliance with oral contraceptive pill. Fetal \nPediatr Pathol. 2015; 34: 103-107.\n16. Pfeffer RI. Membranous dysmenorrhea. Am J Obstet Gynecol. \n1956; 72: 677-679.\n17. Rouanet JP , Daclin PY , Turpin F, Karam R, Prayssac- Salanon A, \net al. Imaging of membranous dysmenorrhea. Eur Radiol. 2001; \n11: 952-954.\n18. Omar HA, Smith SJ. Membranous dysmenorrhea: a case series. \nScientific World Journal. 2007; 7: 1900-1903.","source_license":"CC0","license_restricted":false}