Vaginal polypoid endometriosis

E620 CMAJ | May 1, 2023 | Volume 195 | Issue 17 © 2023 CMA Impact Inc. or its licensors A healthy 34-year-old woman presented to our gyne- cology clinic for treatment of a cervical polyp. Medica- tions included a combined oral contraceptive pill (OCP) and ibuprofen for heavy menstrual bleeding and longstanding dysmenorrhea. She had occasional dyschezia and was not sexually active. Her previous Pap tests were normal. Speculum examination revealed numerous polypoid growths in the right pos- terior vaginal fornix that did not involve the cervix (Figure  1). We undertook a wide local excision in the operating room, and pathology confirmed vaginal polyp oid endometriosis (Appendix  1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.220466/tab -related-content). Focused ultrasonography confirmed an ante- verted, anteflexed uterus with diffuse global adeno- myosis. The patient’s ovaries were normal but relocated to the posterior cervix in the midline as “kissing ovaries,” a sonographic finding associated with severe endo metriosis. The rectosigmoid colon was adherent to the right posterior vagina, the site of polypoid growths. We reviewed medical management options for endometriosis with the patient. She opted to transition from a combined OCP of levonorgestrel and 30  µg ethinyl estradiol to one of norethindrone acetate and a lower dose of ethinyl estradiol (10  µg) for targeted endo metriosis suppression. Her symp- toms improved considerably. Endometriosis is the presence of endometrial-like glands and stroma outside of the uterine cavity. It is associated with pelvic pain and infertility and occurs in 10%–15% of patients of reproductive age. 1 Polyp- oid endometriosis is an uncommon variant of endo- metriosis. It usually presents on the colon and ovar- ies, and occasionally in the vagina, appearing as large polypoid masses; cancer is often suspected before histologic examina- tion. 2 The most common manifestation of vaginal polyp oid endometriosis is postcoital spotting, occasionally leading to hemorrhage. 3 Treatment options for vaginal polypoid endometriosis are similar to those for pelvic endometriosis, with emphasis on symptom control using progestin- or estrogen-suppressive ther- apies. For instance, we used norethindrone acetate, a relatively androgenic estrane progestin with proven effectiveness at con- trolling endometriosis -associated pain. 1 Low-dose ethinyl estradiol with norethindrone acetate, as used in this case, is ideal to reduce stimulation of estrogen-rich endometriotic lesions.1 Vagin al polyp oid lesions can be associated with deep endometriosis involving pelvic structures, the bowel and the vagina. Patients with deep involvement should be referred to a surgeon with expertise in endometriosis when medical man- agement has failed. Practice | Clinical images Vaginal polypoid endometriosis Monique Marguerie MSc MD, Jenika Howell MD, Liane Belland MD n Cite as: CMAJ 2023 May 1;195:E620-1. doi: 10.1503/cmaj.220466 Figure 1: Photograph of vaginal polypoid endometriosis (arrows) visualized during a speculum examination of a 34-year-old woman. Practice CMAJ | May 1, 2023 | Volume 195 | Issue 17 E621 References 1. Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of woman with endometriosis. Hum Reprod 2014;29:400-12. 2. Parker RL, Dadmanesh F, Young RH, et al. Polypoid endometriosis: a clinico - pathologic analysis of 24 cases and a review of the literature. Am J Surg Pathol 2004;28:285-97. 3. Ling R, Hontau J, Yang Y, et al. Polypoid endometriosis of the rectum and vagina in an adolescent. J Pediatr Adolesc Gynecol 2020;33:581-5. Competing interests: Liane Belland reports honoraria from AbbVie, Olympus, Pfizer and Seaford Pharmaceuticals, and advisory board participation with AbbVie. She is the president of CanSAGE and a member with EndoACT. No other competing interests were declared. This article has been peer reviewed. The authors have obtained patient consent. Affiliations: Department of Obstetrics and Gynecology (Marguerie), University of Calgary; Department of Pathology and Laboratory Medi- cine (Howell), Alberta Precision Labs/Alberta Health Services; Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology (Belland), University of Calgary, Calgary, Alta. 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