It's never endometriosis, except when it's endometriosis

We would like to report the conclusion, after the histological response, of an interesting clinical case that we published in July 2022 ( 1 ). It was the case of a 52-year-old woman presented to the Emergency Department complaining of abdominal pain of unknown origin. A CT scan revealed peritoneal free fluid and an active uterine bleeding. Because of a progressive hemodynamic instability, the patient underwent an emergency exploratory laparotomy in our department, that confirmed the hemoperitoneum and a perforated uterus which was removed. The origin of bleeding was referred to an area of perforation of the lower posterior uterine wall near by the cervical area. It was found a circular hole of 1.5 cm. Macroscopically, there were typical signs of thermal damage, with crumbly and fragile tissues ( Figure 1 ). An area of sigmoid colon, behind the uterus perforation, was also showing signs of thermal damage (a circular small mold in the serosa) without bowel perforation. The perforation was, in first hypothesis, related to a thermal damage resulting from a hysteroscopic Endometrial Ablation performed 3 months before for abnormal uterine bleeding, in another hospital. To the best of our knowledge, and according to the literature ( 2 ), it was the first reported case of a late complication (3 months) of an hysteroscopic thermal ablation. We speculated, at the end of the experience, that at the time of first surgery (hysteroscopy) there was no whole thickness perforation but a severe thermal necrosis that with time progressed to the uterine serosa causing at the end, the uterine perforation and the clinical situation we encountered. Area of perforation of the lower posterior uterine wall (in the circle). We have now obtained the histological response, that asserted a severe endometriosis of the cervical wall in a contest of fibroids. It confirms what we stated in our previous work, or rather that the thermal damage and the perforation is more likely when patients have an altered uterine anatomy such as in the presence of fibroids ( 3 ), as it was for the patient. Moreover, because of the endometriosis of the cervical wall, the necrosis progressed during months, causing symptoms not at the end of the hysteroscopic procedure, but three months later. In conclusion, we would like to highlight the importance of taking into consideration, also during minor surgery such as hysteroscopy, the fragility of endometrioid tissues and the uterine anatomy, especially when deformed by fibroids. Nevertheless, our case showed the possibility of a late complication of hysteroscopy, that must be considered when a symptomatology such described, occurs.