A case of unilateral dysmenorrhea
An 18-year-old female presented with pain on the sixth day of her menstrual cycle (troubling since last two years). Pain was felt over the right abdomen starting before the menstrual cycle and reaching its peak during the menstrual cycle.
The patient is at highest possibility of being diagnosed with:
- Abnormal uterine bleeding (AUB)
- Dysmenorrhea : (painful menstrual periods)
- Premenstrual syndrome (PMS)
- Premenstrual dysphonic disorder (PMDD)
Dysmenorrhea refers to painful menstrual cramps of uterine origin associated with menstrual frequency. Primary dysmenorrhea begins during adolescence, occurring in 60% to 93% females with ovulatory cycles.1 Secondary dysmenorrhea is rare and occurs due to the presence of a pelvic disease. The unilateral dysmenorrhea is a very rare complaint in adolescent girls and may be associated with uterine malformation.
An 18-year-old female presented to the outpatient clinic of hospital on the sixth day of her menstrual cycle with pain. She had been experiencing the pain since last two years. She reported that the pain was felt over the right abdomen starting before the menstrual cycle and reaching its peak during the menstrual cycle.
On and off analgesics during the last two years.
Examination and Laboratory Investigation
Physical examination: Per abdominal examination showed tenderness at right iliac fossa.
Ultrasonography: This further suggested differential diagnoses of right-sided hematosalpinx with hematometra and bicornuate uterus with non-visualized right kidney.
MRI examination: It revealed a unicornuate uterus with right-sided functioning cavitary rudimentary horn, right hematometra and hematosalpinx, right renal agenesis and right ovarian hemorrhagic cyst. Moreover, intravenous pyelography also confirmed right renal agenesis.
Cytoscopy: This revealed non-visualization of the right ureteric orifice with normal left ureteric orifice and bladder mucosa.
Laparotomy was performed and showed two separate cornu of uterus with right-sided hematosalpinx and right ovarian hemorrhagic cyst. An anchovy sauce-like material oozed out on incising the right sided horn of the uterus. Further, right-sided rudimentary horn was found to be non-communicating with the main uterine cavity. An excision of the right-sided cornu and right ovariotomy was performed maintaining proper hemostasis. Also, the fallopian tubes and left cornu were and the excised specimen was sent for histopathological examination. The period after the surgery was uneventful. The histopathological reports revealed rudimentary horn with endometrial and myometrial tissue. The right-sided tube showed chronic salpingitis with areas of hemosiderin-laden macrophages and the ovary had features suggestive of simple hemorrhagic follicular cyst. The patient was followed up post surgery and had no further complaint of dysmenorrhea.
Unicornuate uterus with a rudimentary horn is a rare type of mullerian duct malformation.2 It usually occurs following obstruction to the outflow of menstrual blood. The rudimentary horn may be a small solid lump of uterine muscle with no functional endometrium and in 83% cases, it is non-communicating.3 Causes may include endometriosis with unilateral distribution or a small leiomyoma at the uterotubal junction. The mullerian abnormalities may be diagnosed using ultrasonography. However, an MRI is more specific for the evaluation of presence or absence of a functional endometrium. Furthermore, the best way to diagnose mullerian anomaly is diagnostic laparoscopy. To avoid future complications, early diagnosis and excision of the rudimentary horn is advised.
In the present case, the patient did not report of dysmenorrhea after excision of the rudimentary horn. Early diagnosis and prompt treatment is recommended in these cases to avoid future gynecological and obstetrical complications. The right decision with minimal access surgery is the preferred mode of management.
- Latthe P, Latthe M, Say L, Gülmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: neglected reproductive health morbidity. BMC Public Health. 2006; 6:177.
- Raga F, Bauset C, Remohi J, Bonilla-Musoles F, Simón C, Pellicer A. Reproductive impact of congenital mullerian anomalies. Hum Reprod. 1997; 12:2277–81.
- Heinonen PK. Unicornuate uterus and rudimentary horn. Fertil Steril. 1997; 68:224–30.