1. CASE REPORT
Massive ascites as a presentation in a young woman
with endometriosis: a case report
Khalid H. Sait, M.Bch.B., F.R.C.S.C.
Department of Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
Objective: To report a case of endometriosis associated with massive ascites and an elevated CA-125 level.
Design: Case report.
Setting: Tertiary care center.
Patient(s): A 26-year-old woman presented with massive ascites and an increased CA-125 level suggestive of
ovarian cancer.
Intervention(s): Ultrasonography, laparotomy, and bilateral ovarian cystectomy and reconstruction. Endometri-
osis was diagnosed postoperatively on the basis of histopathology. The patient received 6 months of treatment
with a GnRH analogue.
Main Outcome Measure(s): Ultrasound examination 6 months after surgery to evaluate for ascites or recurrent
ovarian cysts.
Result(s): Frozen sections obtained at laparotomy and ovarian cystectomy ruled out a malignancy. The final
histologic report was compatible with a diagnosis of endometriosis. After 6 months of treatment with the
GnRH analogue, the patient experienced a progressive reduction of the ascitic fluid and full remission after 2 years.
Conclusion(s): Endometriosis associated with massive bloody ascites is an unusual occurrence. This report draws
attention to this condition as a complication of endometriosis. For this reason, endometriosis should be included in
the differential diagnosis of reproductive-age women presenting with an apparent ovarian malignancy. (Fertil
SterilÒ 2008;90:2015.e17–e19. Ó2008 by American Society for Reproductive Medicine.)
Key Words: Endometriosis, ovarian cancer, ascites
Endometriosis is defined as the presence of endometrial
tissue outside the uterine cavity, generally involving the
peritoneum, ovaries, and rectovaginal septum. However, it
may also occur at remote sites with unusual manifestations.
Rare examples include pulmonary endometriosis and
endometriosis associated with ascites (1). Endometriosis as-
sociated with massive ascites causing abdominal distension
and other symptoms simulating a malignancy has been de-
scribed in the literature (2–6). Here, we report a case of this
unusually severe form of endometriosis in a patient who
was initially diagnosed with advanced ovarian cancer before
surgery. She presented with an increase in abdominal girth
and was found to have bilateral ovarian cysts, massive hem-
orrhagic ascites, and an elevated CA-125 level.
CASE REPORT
A 26-year-oldsinglewoman reported a history of an increased
abdominalgirthforthepreceding10months.Shehadahistory
of regular normal menstrual periods associated with severe
dysmenorrhea. A review of systems was unremarkable. The
medical and surgical history was noncontributory.
Physical examination revealed a generally well woman
without pallor. Her chest and heart examinations were nor-
mal. Her abdomen was distended with ascites but with no
hepatosplenomegaly or pain upon deep palpation. No masses
could be palpated. Pelvic and abdominal ultrasonography re-
vealed massive ascites with a normal uterus and bilateral
ovarian cysts measuring 8 Â 7 Â 6 cm. They were multiloc-
ular with thick capsules, and the ultrasound appearance was
hypoechogenic. The CA-125 level was 3,140 mIU/mL, and
levels of other tumor markers were all normal. The patient
was counseled regarding the possibility of metastatic ovarian
cancer, and consent was obtained for surgery.
Laparotomy was performed with the following findings: 5
L hemorrhagic ascites, bilateral ovarian cysts with extensive
pelvic adhesions, and areas of reddish color within the pelvic
peritoneum. The uterus was firmly adhered to the rectum and
bladder. Rupture of a cyst during dissection revealed that it
contained a reddish fluid. Bilateral ovarian cystectomy was
performed with reconstruction of both ovaries. Frozen sec-
tions of all biopsy specimens submitted showed benign-look-
ing cysts with no evidence of malignancy. Multiple peritoneal
Received March 1, 2008; revised May 21, 2008; accepted July 9, 2008.
K.S. has nothing to disclose.
Reprint requests: Khalid Sait, M.Bch.B., F.R.C.S.C., Consultant, Gyneco-
logic Oncology, Department of Obstetrics and Gynecology, King Abd
Alaziz University Hospital, Jeddah 21589, PO Box 80215, Saudi Arabia
(FAX: 026408316; E-mail: khalidsait@yahoo.com).
0015-0282/08/$34.00 Fertility and Sterilityâ Vol. 90, No. 5, November 2008 2015.e17
doi:10.1016/j.fertnstert.2008.07.021 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.

2. biopsy specimens were also obtained. Final histopathologic
analysis of the operative specimens confirmed the diagnosis
of endometriosis, and the peritoneal biopsy specimens
showed a lot of inflammation and hemosiderin deposition,
but no evidence of malignancy.
The patient’s postoperative course was unremarkable, and
the patient was discharged home 5 days after surgery. The pa-
tient received 6 months of GnRH analogue treatment.
Ultrasound examination 6 months later revealed no ascites
and no recurrent cysts. Two years later, the patient had no
complaints and was experiencing a regular normal period
while on maintenance treatment consisting of combined birth
control pills.
DISCUSSION
The incidence of endometriosis in the general population is
unknown; however, in women undergoing evaluation for in-
fertility it is generally approximately 30%, and in women
undergoing evaluation for dysmenorrheal/pelvic pain it is
approximately 40%–50% (7). The pathogenesis of endome-
triosis has not yet been fully elucidated. Although endometri-
osis is generally confined to the pelvis, it may occur at remote
sites (1).
The association of endometriosis with massive bloody as-
cites is extremely rare. Brews (8) reported the first case in
1958. Thirty additional cases have been reported since
then, representing a diagnostic dilemma for gynecologists,
owing to their rarity and to the fact that these cases mimic
malignant ovarian neoplasms (2–6, 9–32).
In the previously reported cases, the endometriosis in-
volved mainly the peritoneum, frequently occurring in its
most severe form in association with multiple adhesions
and ovarian endometriomas (50% of cases). Ascitic fluid,
the common denominator in all of the cases, was detected
in large volumes (4,254 mL on average) and was bloody in
50% of cases and brown in the other 50% of cases. Ascitic
fluid associated with endometriosis is of an exudative nature
(19, 21, 33) and may originate as a result of peritoneal irrita-
tion caused by the presence of blood in the cavity due to the
rupture of endometrial cysts. The rapid production of fluid by
inflamed tissue and the obstruction of subdiaphragmatic
lymph vessels, which impair its reabsorption, may be respon-
sible for the large volumes detected (5, 9, 19, 24, 28, 29).
There has been no consistency regarding the treatment of as-
cites associated with endometriosis in young patients. In the
present case, therewas no recurrence of ascites during an obser-
vation period of approximately 2 years after conservative surgi-
calresectionandsuppressionofovulationwithaGnRHagonist.
Endometriosis-associated ascites is commonly mistaken
for ascites caused by ovarian neoplasms, especially when as-
sociated with an elevated CA-125 level, which is a tumor
marker for ovarian neoplasms. The CA-125 level may be
so strikingly elevated that the diagnosis of ovarian malig-
nancy appears certain. Kahraman et al. reported values as
high as 7,900 mIU/mL associated with endometriosis (34).
Endometriosis associated with massive bloody ascites is an
unusual occurrence.
The present report draws attention to this condition as
a complication of endometriosis and may suggest that
GnRH therapy could be used to prevent the accumulation
of ascites after surgical resection in young patients who
wish to preserve fertility. Our findings also suggest that endo-
metriosis associated with massive bloody ascites should be
included in the differential diagnosis of reproductive-age
women presenting with an apparent ovarian malignancy.
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