Miss Y, 37 years old, was known to have bilateral ovarian endometrial cysts, which were treated surgically by Mr D, a consultant gynaecologist. Repeat scans after surgery showed recurrence of the cysts, which were subsequently managed with dydrogesterone.
She subsequently presented as an emergency, complaining of severe dysmenorrhoea for three days. Bilateral ovarian cysts were again confirmed on a trans-vaginal ultrasound scan and a decision was made for her to undergo further surgery.
Mr D performed a laparotomy and found recurrent bilateral ovarian cysts stuck down in the pouch of Douglas and adherent to the back of the broad ligament. Both fallopian tubes were dilated but otherwise normal. Mr D recorded that the right ovary was freed and chocolate coloured material aspirated.
The left ovary was drained in situ, but no attempt was made to free it. Before the operation, Mr D inserted a small pack into the posterior fornix in an attempt to keep the uterus and ovaries elevated. Miss Y had never been sexually active.
Miss Y made an uneventful recovery and was discharged from hospital on day four. Three weeks later she was referred back to the gynaecology department with increasing pain and urinary incontinence. Clinical examination demonstrated left iliac fossa tenderness but an ultrasound scan was negative.
A diagnosis of dysmenorrhoea, secondary to endometriosis, was made as the patient had begun menstruating two days earlier. The patient declined admission to hospital as she was anxious to go home. Mefenamic acid was prescribed and she was reviewed by Mr D two weeks later.