Unusual Manifestation of Membranous Dysmenorrhea: Case Report

Background

Dysmenorrhea, or painful menstruation, is a gynecologic entity affecting between 16% and 91% of women of reproductive age. However, its pathophysiology is still incompletely understood [1,2]. Dysmenorrhea is characterized by its occurrence mainly at the beginning of the menstrual cycle. It is divided into primary, colicky, and lower abdominal pain during menstruation and is not associated with other diseases or pathologies. By contrast, secondary dysmenorrhea is usually associated with another pathology inside or outside the uterus [2].

Membranous dysmenorrhea is characterized by the detachment of the endometrium, which can maintain the shape of the uterus [1]. In the 18th century, Morgagni described membranous dysmenorrhea in his work “De sedihus et causis morburum” as an abrupt and complete detachment of the decidua during menstruation, which behaves like a foreign body in the uterine cavity, producing intense and painful myometrial contractions to expel it [3].

We present the clinical case of a patient in her fifth decade of life who had intense abdominal pain in the hypogastrium and transvaginal bleeding, showing the expulsion of a total and complete endometrial form.

Case Report

A 43-year-old female patient presented with no history of dysmenorrhea or pelvic pain and no significant family or past medical history. Obstetric and gynecologic history included menarche at 14 years of age, regular menstrual cycles, 3 pregnancies with cesarean deliveries, and current method of family planning of bilateral tubal occlusion 8 years prior after the last obstetric event. The patient was evaluated at the hospital Emergency Department because she presented with severe hypogastric cramping pain and acute onset of transvaginal bleeding.

Physical examination of the patient revealed a flat abdomen after respiratory movements, absence of skin lesions with a cesarean scar, pain on superficial and deep palpation in the hypogastric region, and no evidence of peritoneal irritation or palpable tumors. Speculum examination revealed a pink vagina with traces of blood and expulsion of tissue (endometrial form) at the external cervix, which was removed with ring forceps. The tissue had the appearance of a complete endometrial cast of the uterine cavity (Figure 1). Upon removal of the tissue, the patient experienced pain relief and immediate clinical improvement. The tissue was placed in a formalin flask and sent to the Anatomic Pathology Department for histopathologic diagnosis. Histopathological examination confirmed the microscopic features of membranous dysmenorrhea, showing pre-decidualized endometrial tissue with dilated and congested vessels (Figure 2).

The patient was discharged from the Emergency Department and referred monthly to the Outpatient Clinic. She experienced no new episodes after 3 consecutive menstrual cycles; therefore, it was decided to release her with open appointments in the Emergency Department, as needed.

Discussion

Membranous dysmenorrhea is a rare entity with an acute onset clinical picture characterized by severe hypogastric pain and transvaginal bleeding [4,5]. The definitive diagnosis is made by histopathological examination of the expectorated tissue, which shows an endometrium with abundant pre-decidualized stroma, with elongated cells infiltrated by polymorphonuclear cells and glands lined by cuboidal cells without atypia [1,2].

Among the possible causes is the theory of hyperestrogenism since, in some cases, it has been observed that the expulsion of decidualized spongy tissue occurs after using progesterone [6]. Another hypothesis is a generalized increase in progesterone and estrogen secretion, with consequent thickening of the endometrium, incomplete expulsion of the tissue, and overdevelopment of the spiral arteries, leading to vasodilation, followed by vasoconstriction and sloughing of the over-developed endometrium [7].

There are few publications on this entity because it is a pathology of low incidence in women over 40 years of age [8]. The case of our patient was an atypical presentation according to other case reports, since she was neither in adolescence nor using hormonal contraceptive methods that could have influenced the onset of membranous dysmenorrhea; however, the clinical characteristics and their association with this pathology allowed the diagnosis and its confirmation by histopathology.

Conclusions

Membranous dysmenorrhea is a rare gynecological pathology. There are few references of cases, and it is associated with oral contraceptive use, ectopic pregnancy, abortions, and natural cycles, with consequent thickening and endometrial decidualization with molding of the uterine cavity tissue with a membranous appearance. Data on cause, incidence, and recurrence are not known with certainty, so when a case is presented, it should be reported to generate information and act based on evidence-based medicine.