LAUSR

Uterine myoma is a common disease. Twenty to 80% of women develop myoma before they reach age 50 years.1,2 Common symptoms of myoma are menorrhagia, abdominal pain, or subfertility. Here, we report a rare case of secondary amenorrhea with cyclic abdominal pain secondary to obstructive myoma. A 43-year-old G1P1 woman presented at our hospital with secondary amenorrhea. She had undergone cesarean section 10 years earlier, and her regular period resumed after several months. However, for the past 3 years, she had had intermittent abdominal pain with amenorrhea. She was 163 cm tall and weighed 50 kg. Pelvic examination revealed a uterus of normal size and no adnexal masses. Transvaginal ultrasonography showed a uterus of normal size with normal endometrial thickness (4 mm), normal ovaries, and no echo-free space. It also revealed a hyperechoic solid mass near a cesarean section scar (Figure 1A). A blood test revealed that she had an elevated carbohydrate antigen-125 level (96.6 U/ mL) and her estradiol and follicle-stimulating hormone levels were 240 pg/mL and 2.3 mIU/mL, respectively. She had no withdrawal bleeding after a progesterone test, but presented with abdominal pain and free fluid in the pouch of Douglas on ultrasound. Magnetic resonance imaging demonstrated an inhomogeneous mass (20 mm 14 mm 8 mm) near a cesarean section scar (Figure 1B). The presumed diagnosis at that time was secondary amenorrhea caused by obstructive myoma. During the next menstrual period, the patient underwent hysteroscopy and laparoscopy under general anesthesia. Laparoscopy indicated that the reproductive organs and any other organs examined were normal in size and appearance. However, it revealed sings of bleeding through the fallopian tubes into the peritoneal cavity, as well as the presence of endometriotic lesions in the peritoneal cavity (Figures 2A and 2B). The endometriotic lesions were vaporized using argon plasma (Figure 2C). Histological confirmation of endometriosis was not performed. Hysteroscopy was performed using a standard 24Fr irrigating monopolar resectoscope. Cervical priming before surgery was not done because she complained of severe pain. The cervix was dilated with a size 10 Hagar dilator. The uterine cavity was irrigated using Uromatic S (Baxter,