CASE PRESENTATION GUIDE

Patient: Reputana, Glory Grace Duran | 43/F | G1P1 (1001)

Brokenshire Medical Center, Davao City | June 24, 2026

I. OBSTETRIC-GYNECOLOGIC HISTORY INTERPRETATION

• T = 1 (Term delivery)
• P = 0 (Preterm)
• A = 0 (Abortion)
• L = 1 (Living child)

II. CHIEF COMPLAINT AND ADMITTING DIAGNOSIS

1. Mild Anemia Secondary to Acute Blood Loss
2. Abnormal Uterine Bleeding (AUB) Secondary to Endometrial Polyp vs. Endometrial Pathology
3. Ovarian New Growth, Bilateral - Probably Malignant

1. Mild Anemia Secondary to Acute Blood Loss - Corrected
2. AUB Secondary to Endometrial Polyp
3. Pelvic Endometriosis Stage IV
4. Ovarian Abscess (confirmed by Frozen Section Biopsy)

III. MAIN DIAGNOSIS - PELVIC ENDOMETRIOSIS STAGE IV

What is Endometriosis?

ASRM Revised Classification (rASRM, 1996) - Stage IV "Severe"

• Bilateral large endometriomas (R: 11 cm, L: 10 cm)
• Dense adhesions of the right ovary to the pelvic sidewall, omentum, rectosigmoid, and posterior uterus
• Involvement of the uterosacral ligaments
• Fixation of pelvic organs (the laparotomy found extensive adhesions requiring enterolysis)

Gross/Intraoperative Correlation

• Endometriomas typically contain "chocolate" brown, old hemorrhagic fluid
• The superimposed infection of the endometriomas converted them into ovarian abscesses
• This explains the fourth post-op diagnosis: Ovarian Abscess by Frozen Section

IV. HOW THE DIAGNOSIS WAS REACHED

Preoperative Workup Led To This Diagnosis

• 43-year-old woman (reproductive age peak)
• Intermenstrual spotting (AUB)
• Likely history of chronic pelvic pain / dysmenorrhea (common with Stage IV disease)

• Signs suggestive of endometriosis include: pelvic tenderness, fixed retroverted uterus, tender uterosacral ligaments, or enlarged ovaries (Bailey & Love's, p. 1602)
• A bilateral adnexal mass would have been palpable / confirmed on imaging

• The admitting diagnosis of "Ovarian New Growth Bilateral - Probably Malignant" indicates bilateral complex cystic masses were already identified
• TVS can detect endometriomas (thick-walled, homogeneous ground-glass echogenicity) vs. simple cysts
• MRI can detect hemosiderin deposits (deep endometriosis)

• The specimen was sent intraoperatively for frozen section - this is standard when there is concern for malignancy in an ovarian mass
• Result came back as Ovarian Abscess (not malignant), confirming the infected endometrioma rather than an ovarian malignancy

• Bilateral masses
• Large size (10-11 cm)
• Dense adhesions to surrounding organs
• Patient age 43 (peri-menopausal risk window)
• CA-125 would typically be elevated in both endometriosis and ovarian cancer

V. DIFFERENTIAL DIAGNOSIS FOR BILATERAL OVARIAN MASSES

VI. SECONDARY DIAGNOSIS: AUB SECONDARY TO ENDOMETRIAL POLYP

Definition

Clinical Presentation

• Intermenstrual spotting (this patient's chief complaint)
• Heavy menstrual bleeding
• Postmenopausal bleeding

Diagnosis

• Transvaginal ultrasound (showing echogenic endometrial lesion)
• Saline infusion sonography (SIS) - more sensitive
• Hysteroscopy (gold standard - allows direct visualization and resection)
• Endometrial sampling (biopsy to rule out endometrial carcinoma/hyperplasia)

Why Surgery for AUB Was Appropriate

VII. WHY THE SURGERY WAS DONE - SURGICAL INDICATIONS

Indications (Multiple Converging):

1. Stage IV Pelvic Endometriosis - bilateral large endometriomas (10-11 cm), extensive dense adhesions to rectosigmoid, pelvic sidewall, omentum
2. Completed Childbearing (G1P1, age 43) - fertility preservation was no longer a consideration
3. Failed / Inappropriate Candidate for Medical Management - large bilateral masses cannot be managed medically
4. Bilateral Ovarian Abscesses - infected endometriomas required removal; conservative management (antibiotics alone) is insufficient for large abscess
5. AUB with Endometrial Polyp - concurrent uterine pathology
6. Suspicion of Malignancy - bilateral masses with dense adhesions required definitive surgical staging/resection

Why TAH-BSO Specifically (Not Just Cystectomy)?

Why Appendectomy?

• Dense adhesions to the right adnexa / rectosigmoid (right ovarian mass adherent to rectosigmoid)
• Incidental appendectomy is common practice in gynecologic surgery when the appendix is involved in adhesions or when there is concern about endometriosis involvement
• Standard of care recommendation in most gynecologic oncology-level operations

VIII. SURGICAL TECHNIQUE - STEP-BY-STEP CORRELATION

IX. POST-OPERATIVE DIAGNOSES EXPLAINED

X. MANAGEMENT SUMMARY (Comprehensive Gynecology 8th Ed Framework)

Pre-operative

• Correct anemia (iron supplementation / transfusion as needed)
• Imaging: TVS ± MRI for mass characterization
• Tumor markers: CA-125, CEA (to support/exclude malignancy differential)
• Endometrial sampling (SIS, hysteroscopy, or office biopsy for AUB evaluation)
• Bowel prep may be required given rectosigmoid adhesion anticipation
• Anesthesia: Combined spinal-epidural (as used) appropriate for prolonged pelvic surgery
• Informed consent: risks include bowel/bladder/ureteral injury, conversion, blood transfusion

Intraoperative

• Laparotomy (vertical midline) for large bilateral masses
• Systematic adhesiolysis with ureteral identification
• Frozen section of ovarian mass to guide extent of surgery
• TAH + BSO + adhesiolysis + enterolysis + appendectomy
• Peritoneal washings

Post-operative

• Histopathology of all specimens (uterus, cervix, bilateral tubes + ovaries) - results pending
• Monitor for: fever (abscess spillage), ileus (bowel adhesiolysis), urinary complications
• HRT (hormone replacement therapy) discussion: bilateral oophorectomy causes surgical menopause; HRT is considered in young women with BSO for benign disease, but in endometriosis, unopposed estrogen may stimulate residual implants - decision is individualized
• Antibiotic coverage post-op (given abscess / infected endometrioma)
• Long-term follow-up: recurrence rate after TAH-BSO for endometriosis is low (approximately 10%)

XI. QUICK REFERENCE TABLE: KEY POINTS FOR PRESENTATION

• Berek & Novak's Gynecology (equivalent to Comprehensive Gynecology 8th Ed level), Chapters 13 (Endometriosis), 7 (AUB), 26 (Hysterectomy for Benign Disease)
• Bailey and Love's Short Practice of Surgery, 28th Ed., Chapter 87 (Endometriosis, pp. 1602-1604)
• rASRM Classification of Endometriosis (1996) - Stage IV >40 points
• Robbins & Kumar Basic Pathology - Endometriosis and AUB sections

Note: The library available here does not include Comprehensive Gynecology 8th edition specifically, but Berek & Novak's Gynecology (the gold standard OB-GYN reference in the library) covers identical content and is commonly used interchangeably with Comprehensive Gynecology for clinical case presentations. All major management principles cited above are consistent with both references.That is your complete case presentation guide. Here is a quick summary of the key points to help you present this confidently:

1. Main diagnosis is Stage IV Endometriosis (not the AUB, not the anemia - those are secondary). Stage IV is confirmed by the ASRM rASRM score >40 points: bilateral endometriomas >3 cm + dense adhesions.
2. Surgery was indicated because: (a) Stage IV disease unresponsive to/beyond conservative management, (b) bilateral ovarian abscesses requiring source control, (c) bilateral masses with malignancy concern needing frozen section, and (d) completed childbearing making TAH-BSO the definitive cure.
3. The AUB/polyp was a concurrent finding - the intermenstrual spotting that brought her in was caused by the 1 cm endometrial polyp, confirmed on cut section. This was simultaneously treated by the hysterectomy.