Endomyometriosis ("Uterus-like mass") in an XY Male: Case Report With Molecular Confirmation and Literature Review

Hematospermia in a Transgender Woman with Evidence for Endometrial Tissue in the Prostate

Background/Objective

The frequency of hematospermia in transgender women is unknown. This report aimed to describe the development of hematospermia in a transgender woman.

Case Report

A 35-year-old transgender woman treated with estradiol valerate and leuprolide presented with painless rust-tinged ejaculate, urethral bleeding after ejaculation, and intermittent hematuria. Her medical history included gastroesophageal reflux disease, internal hemorrhoids, and attention deficit hyperactivity disorder with negative tobacco smoking and urologic history. Additional medications included emtricitabine-tenofovir disoproxil fumarate and fexofenadine. Physical examination did not reveal constitutional or genitourinary abnormalities. Urinalysis and culture disclosed rare white blood cells with gram-variable bacilli. The chlamydia, gonorrhea, and human immunodeficiency virus test results were negative. Abdominal computed tomography did not reveal bladder or prostate cancer, calcifications, inflammation, or cysts. She continued to have symptoms after this initial workup. One year after the initial symptom onset, transrectal ultrasound disclosed a 1.7-cm midline posterior prostatic cyst with hemorrhagic products, later revealed by magnetic resonance imaging as communicating with the left seminal vesicle. Two ultrasound-guided transperineal biopsy samples revealed benign prostatic tissue with a small focus of Müllerian or endometrial-type tissue, evidenced by immunopositivity for paired-box gene 8 and estrogen receptor in epithelium and cluster of differentiation 10 immunopositivity in stroma. After medical consultation, the patient underwent prostatic cyst aspiration, resection of the transurethral ejaculatory ducts, and orchiectomy. She did not experience any complications after these procedures.

Discussion

The etiology of hematospermia may be idiopathic, iatrogenic, anatomic, or pathologic.

Conclusion

Occult endometriosis or ectopic Müllerian epithelial tissue growth may occur in transgender women taking feminizing gender-affirming hormone therapy.

Retroperitoneal 'uterus-like mass' of cervical origin

We report a rare case of a retroperitoneal uterus-like mass communicating with the endocervix, which presented as abdominal pain and bloating associated with severe irregular vaginal and postcoital bleeding. Our patient did not have any structural abnormalities of the urogenital system or otherwise, which makes a müllerian defect unlikely in our case. Based on the diagnostic criteria for the choristoma, that theory would be excluded here as the mass communicated with the endocervix. This strengthens the theory of metaplasia, under the effect of oestrogen and accelerated by the hyperoestrogenic state of pregnancy as the most likely postulate for our patient. Although the uterus-like mass is not commonly reported, it should be considered as a possible differential for pelvic masses.

Primary Retroperitoneal Carcinomas: New Insights into Pathogenesis and Clinical Management in Comparison with Ovarian Carcinomas and Carcinoma of Unknown Primary

Primary retroperitoneal carcinomas are very rare tumors. Their pathogenesis remains unknown but may be associated with that of ovarian carcinomas, considering the similarity in morphology and gender preference. Although metaplasia of coelomic epithelium is the most widely accepted theory, the pathogenesis of retroperitoneal carcinomas may differ by histologic subtype, like ovarian carcinomas. Mucinous carcinoma, which develops in both women and men, may originate in both primordial germ cells and Walthard cell nests that may be derived from the fallopian tube. Serous carcinomas may be associated with endosalpingiosis, the presence of fallopian tube-like epithelium outside the fallopian tube, and a remnant Müllerian tract. Endometrioid and clear cell carcinomas appear to be associated with extraovarian endometriosis. Additionally, both carcinomas in the retroperitoneal lymph nodes may be metastatic diseases from endometrial and/or renal cell cancer that regress spontaneously (carcinoma of unknown primary). Retroperitoneal carcinomas are difficult to diagnose, as they have no characteristic symptoms and signs. Surgery is the cornerstone of treatment, but the necessity of chemotherapy may depend on histological subtype. Further studies are necessary, in particular studies on endosalpingiosis, as endosalpingiosis is a poorly understood condition, although it is associated with the development of both serous and mucinous carcinomas.

Female reproductive health impacts of Long COVID and associated illnesses including ME/CFS, POTS, and connective tissue disorders: a literature review

Long COVID disproportionately affects premenopausal women, but relatively few studies have examined Long COVID's impact on female reproductive health. We conduct a review of the literature documenting the female reproductive health impacts of Long COVID which may include disruptions to the menstrual cycle, gonadal function, ovarian sufficiency, menopause, and fertility, as well as symptom exacerbation around menstruation. Given limited research, we also review the reproductive health impacts of overlapping and associated illnesses including myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), postural orthostatic tachycardia syndrome (POTS), connective tissue disorders like Ehlers-Danlos syndrome (EDS), and endometriosis, as these illnesses may help to elucidate reproductive health conditions in Long COVID. These associated illnesses, whose patients are 70%-80% women, have increased rates of dysmenorrhea, amenorrhea, oligomenorrhea, dyspareunia, endometriosis, infertility, vulvodynia, intermenstrual bleeding, ovarian cysts, uterine fibroids and bleeding, pelvic congestion syndrome, gynecological surgeries, and adverse pregnancy complications such as preeclampsia, maternal mortality, and premature birth. Additionally, in Long COVID and associated illnesses, symptoms can be impacted by the menstrual cycle, pregnancy, and menopause. We propose priorities for future research and reproductive healthcare in Long COVID based on a review of the literature. These include screening Long COVID patients for comorbid and associated conditions; studying the impacts of the menstrual cycle, pregnancy, and menopause on symptoms and illness progression; uncovering the role of sex differences and sex hormones in Long COVID and associated illnesses; and addressing historical research and healthcare inequities that have contributed to detrimental knowledge gaps for this patient population.

Extrapelvic “Uterus Like Mass” Following Laparoscopic Morcellation Hysterectomy - a Consequence of Iatrogenic Implantation?

Uterus-like mass (ULM) is a rare form of endometriosis, which shows striking structural similarity to the normal uterus. Formation of a mass lesion raises clinical concern for malignancy, and pathologic examination is necessary for accurate diagnosis. We describe herein, a middle aged woman who presented with a mesenteric mass six years post hysterectomy, which was initially suspected to be a gastrointestinal stromal tumor. The resected was specimen was grossly pear shaped with microscopy showing a central endometrial glands and stroma lined cavity, surrounded by a thick muscular wall reminiscent of uterine myometrium. Histogenesis of this entity is unclear, and several theories are proposed regarding the etiology, including congenital anomaly theory, metaplasia and heterotopia theories. Our clinical scenario developed a few years after uterine morcellation, indicating a possibility of another “iatrogenic implantation” theory behind the pathogenesis of this rare lesion.

Mullerianosis of urinary bladder: The great impersonator

Müllerianosis of the urinary bladder is a rare entity with less than 30 cases reported. It encompasses a mixture of different types of Mullerian lesions like endometriosis, endocervicosis, and endosalpingiosis. It typically affects the women of reproductive age group. The symptoms vary from hematuria and dysuria, to pelvic pain, which may be associated with menstruation. It can mimic a malignant tumor clinically and radiologically; hence, it is important that a correct diagnosis is rendered in these cases to avoid unnecessary radical procedures. Herein we report a case of mullerianosis of the urinary bladder in a young female and discuss the important differential diagnosis and various treatment modalities.

Endometriosis in a Man as a Rare Source of Abdominal Pain: A Case Report and Review of the Literature

Endometriosis occurs when a tissue resembling endometrial glands and stroma grows in ectopic sites, commonly causing infertility and pain. This condition is most often seen in women of reproductive age, involving pelvic sites such as the ovaries, broad ligaments, uterosacral ligaments, and posterior cul-de-sac. Very rarely, endometriosis has also been found in the lower genitourinary tract of men. A 40-year-old man presented to his primary care physician with abdominal pain. Further imaging discovered a midline mass. Surgical removal of the mass and histological investigations led to the diagnosis of endometriosis. There are multiple theories on the etiology of both female and male endometriosis. The prevailing risk factor proposed in previous cases of male endometriosis is prolonged exposure to estrogen therapy. Should endometriosis become symptomatic, cessation of estrogen therapy and careful surgical intervention may successfully relieve the associated symptoms.

Endometriosis origin from primordial germ cells

Endometriosis is defined by the presence of endometrial ectopia. Multiple hypotheses have been postulated to explain the etiology of endometriosis to understand various clinical evidences. The etiology of endometriosis is still unclear.The primary question to understanding the etiology of endometrial ectopia (endometriosis) is determining the origin of eutopic (normally cited) endometrium.According to the new theory, primordial germ cells migrate from hypoblast (yolk sac close to the allantois) to the gonadal ridges. The gonadal ridges which composed of primordial germ cells derive to the: eutopic endometrium, ovary, ovarian ligament and ligamentum teres uteri.There are 2 principal processes in uterine organogenesis: the intersection of gonadal ridges with mesonephral ducts to form the uterine folds with an endometrial cavity and the fusion of the both uterine folds together to form the unicavital (normal) uterus. In the uterine folds there are closer cell-to-cell communications, polypotential germ cells differentiate and grow into myometrium and endometrial layers.Some of the polypotential germ cells fail to reach the ridges and stay in the peritoneal cavity, where they may be transforming into external endometrial heterotopies.The main insight in the etiology of endometriosis is polypotential germ cells origin, which may explain its potency, pathogenesis and expansion.

Uterus-like mass: A very rare and elusive entity a case report

BACKGROUND

Uterus-like mass (ULM) is an extremely rare lesion. Gross morphology of ULM resembling a uterus. It can occur in various organs in the abdominal cavity, even in the spinal cord. The histogenesis of ULM remains uncertain. A number of hypotheses have been proposed including metaplasia, congenital anomaly, and heterotopia theory.

METHODS

We describe a case of 43-year-old male presented with a complaint of acute low abdominal pain. Pelvic ultrasound found a large pelvic mass embedded in the broad ligament.

RESULTS

The mass contains a variable thickness smooth muscle layer lined with endometrial glands and stroma which resembling a uterus. Eventually, the patient was diagnosed as ULM by histopathological examination.

CONCLUSION

Except hypomenorrhea, the patient did not have any other associated abnormalities. We suggest this case supports the metaplasia theory that ULM is a benign mass formed by the proliferation of ectopic endometrial stromal cells or pluripotent mesenchymal cells of the 2nd Müllerian system.

A rare case of endometrioma in a bitch

Background

Endometriosis is ectopic development of endometrial glands and stroma in extra-uterine sites and if the lesions occur as a well-defined mass is referred to as endometrioma. In the literature, endometrioma has been reported in only women and there are no reports of endometrioma in animals, including non-human primates.

Case presentation

A rare case of endometrioma is reported in an 11-year-old female German Shepherd with clinical signs of dehydration, anemia and prostration. Necropsy revealed ascites, generalized pallor, and a well-demarcated reddish mass adjacent to the left ovary and uterus and adherent to the retroperitoneum. The mass measured 25.0 × 20.0 cm with intermingled soft and firm areas. Upon incision, the mass was found to be solid with variable sized cystic cavities filled with coagulated blood. Microscopically, the mass was composed of cuboidal or prismatic epithelial cells arranged in tubules or acini. The epithelium of the mass had similar characteristics to the normal endometrium with PAS-positive secretions. The stroma was prominent and formed by loose connective tissue and smooth muscle fibers as confirmed by Masson trichrome. Extensive multifocal areas of hemorrhage were also observed in the stroma of the mass and in the interior of some epithelium-lined, cystic structures. Most of the epithelial cells had strong and diffuse cytokeratin expression, and some had vimentin expression. Epithelial and stromal cells also showed ERβ, AR, VEGF and COX2 expression. The stroma showed areas with strong and diffuse vimentin expression. Factor VIII expression was observed only in the endothelium of blood vessels in the stroma.

Conclusions

The macroscopic, microscopic and immunohistochemical findings are consistent with an endometrioma.