{"paper_id":"c3ff14b1-8338-4b85-9321-a31c675bed1c","body_text":"E620 CMAJ  |  May 1, 2023  |  Volume 195  |  Issue 17 © 2023 CMA Impact Inc. or its licensors\nA healthy 34-year-old woman presented to our gyne-\ncology clinic for treatment of a cervical polyp. Medica-\ntions included a combined oral contraceptive pill \n(OCP) and ibuprofen for heavy menstrual bleeding \nand longstanding dysmenorrhea. She had occasional \ndyschezia and was not sexually active. Her previous \nPap tests were normal. Speculum examination \nrevealed numerous polypoid growths in the right pos-\nterior vaginal fornix that did not involve the cervix \n(Figure  1). We undertook a wide local excision in the \noperating room, and pathology confirmed vaginal \npolyp oid endometriosis (Appendix  1, available at \nwww.cmaj.ca/lookup/doi/10.1503/cmaj.220466/tab  \n-related-content).\nFocused ultrasonography confirmed an ante-\nverted, anteflexed uterus with diffuse global adeno-\nmyosis. The patient’s ovaries were normal but \n relocated to the posterior cervix in the midline as \n“kissing ovaries,” a sonographic finding associated \nwith severe endo metriosis. The rectosigmoid colon \nwas adherent to the right posterior vagina, the site of \npolypoid growths. We reviewed medical management \noptions for endometriosis with the patient. She opted \nto transition from a combined OCP of levonorgestrel \nand 30  µg ethinyl estradiol to one of norethindrone \nacetate and a lower dose of ethinyl estradiol (10  µg) \nfor targeted endo metriosis suppression. Her symp-\ntoms improved considerably.\nEndometriosis is the presence of endometrial-like \nglands and stroma outside of the uterine cavity. It is \nassociated with pelvic pain and infertility and occurs \nin 10%–15% of patients of reproductive age. 1 Polyp-\noid endometriosis is an uncommon variant of endo-\nmetriosis. It usually presents on the colon and ovar-\nies, and occasionally in the vagina, appearing as large polypoid \nmasses; cancer is often suspected before histologic examina-\ntion. 2 The most common manifestation of vaginal polyp oid \nendometriosis is postcoital spotting, occasionally leading to \nhemorrhage. 3\nTreatment options for vaginal polypoid endometriosis are \nsimilar to those for pelvic endometriosis, with emphasis on \nsymptom control using progestin- or estrogen-suppressive ther-\napies. For instance, we used norethindrone acetate, a relatively \nandrogenic estrane progestin with proven effectiveness at con-\ntrolling endometriosis -associated pain. 1 Low-dose ethinyl \nestradiol with norethindrone acetate, as used in this case, is \nideal to reduce stimulation of estrogen-rich endometriotic \nlesions.1 Vagin al polyp oid lesions can be associated with deep \nendometriosis involving pelvic structures, the bowel and the \nvagina. Patients with deep involvement should be referred to a \nsurgeon with expertise in endometriosis when medical man-\nagement has failed.\nPractice  |  Clinical images\nVaginal polypoid endometriosis\nMonique Marguerie MSc MD, Jenika Howell MD, Liane Belland MD\nn Cite as: CMAJ 2023 May 1;195:E620-1. doi: 10.1503/cmaj.220466\nFigure 1: Photograph of vaginal polypoid endometriosis (arrows) visualized during a \nspeculum examination of a 34-year-old woman.\n\nPractice\n CMAJ  |  May 1, 2023  |  Volume 195  |  Issue 17 E621\nReferences\n1. Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of \nwoman with endometriosis. Hum Reprod 2014;29:400-12.\n2. Parker RL, Dadmanesh F, Young RH, et al. Polypoid endometriosis: a clinico -\npathologic analysis of 24 cases and a review of the literature. Am J Surg Pathol \n2004;28:285-97.\n3. Ling R, Hontau J, Yang Y, et al. Polypoid endometriosis of the rectum and \nvagina in an adolescent. J Pediatr Adolesc Gynecol 2020;33:581-5.\nCompeting interests: Liane Belland reports honoraria from AbbVie, \nOlympus, Pfizer and Seaford Pharmaceuticals, and advisory board \nparticipation with AbbVie. She is the president of CanSAGE and a \nmember with EndoACT. No other competing interests were declared.\nThis article has been peer reviewed.\nThe authors have obtained patient consent.\nAffiliations: Department of Obstetrics and Gynecology (Marguerie), \nUniversity of Calgary; Department of Pathology and Laboratory Medi-\ncine (Howell), Alberta Precision Labs/Alberta Health Services; Division \nof Minimally Invasive Gynecologic Surgery, Department of Obstetrics \nand Gynecology (Belland), University of Calgary, Calgary, Alta. \nContent licence: This is an Open Access article distributed in accord-\nance with the terms of the Creative Commons Attribution (CC BY-NC-ND \n4.0) licence, which permits use, distribution and reproduction in any \nmedium, provided that the original publication is properly cited, the \nuse is noncommercial (i.e., research or educational use), and no modifi-\ncations or adaptations are made. See: https://creativecommons.org/\nlicenses/by-nc-nd/4.0/\nCorrespondence to: Monique Marguerie,  \nmonique.marguerie@albertahealthservices.ca\nClinical images are chosen because they are particularly intriguing, \nclassic or dramatic. Submissions of clear, appropriately labelled high-\nresolution images must be accompanied by a figure caption. A brief \nexplanation (300 words maximum) of the educational importance of \nthe images with minimal references is required. The patient’s written \nconsent for publication must be obtained before submission.","source_license":"CC0","license_restricted":false}