OP17.08: Sonographic based triage for symptomatic deep infiltrating endometriosis treated with a levonorgestrel‐releasing intrauterine system

To report three cases of severely symptomatic deep infiltrating endometriosis managed by transvaginal sonography (TVS) and by a levonorgestrel-releasing intrauterine system (LNG-IUS). A 34 years-old woman was admitted for severe dysmenorrhea and dyspareunia, menorrhagia and severe anemia. The patient was previously unsuccessfully treated with tranexamic acid, progestins, danazol, GnRH analogues and endometrial resection. TVS showed an enlarged uterus, with inhomogeneous and thickened posterior myometrium, with focal honeycomb lesions highly and irregularly vascularized, typical for deep adenomyosis. A LNG-IUS was inserted. At 48 months follow-up, the patient was free of symptoms. A 38-year-old woman presented with cyclic worsening dysmenorrhea, deep dyspareunia and dyschezia during the last year. TVS showed normal uterus and ovaries, and on the left, an inhomogeneous hypoechoic lesion which infiltrate the antimesenteric sigmoid wall, painful at push-and-pull maneuvers, highly suspicious for sigmoid endometriosis. Barium enema confirmed the TVS image. By the imaging diagnosis of endometriosis, a LNG-IUS was placed. At 21 months follow-up, the patients referred dramatically improvement of symptoms with pain only evoked by deep pelvic exam. A 41 years-old woman was referred with a recent history of severe dysmenorrhea and dysuria. TVS showed an inhomogeneous polypoid 3 cm lesion involving the vesical base and vesicouterine septum. Cystoscopy confirmed a polypoid extramucosal lesion close to uretero-vesical junction. A LNG-IUS was inserted. At 8 months follow-up, the patient persisted free of symptoms. Accurate diagnosis by TVS of deep infiltrating endometriosis may permit a conservative medical treatment based on LNG-IUS.