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Endometriosis of the cervix uteri
ENDUMETRIOSIS BROOKS RAMSEY, (From of
OF THE
CERVIX
UTERI+
M.S., M.D., AND JOSEPH T. CHUNG, MS., M.D., YANKTON,
S. D.
the Department of Obstetrics and Gynecology, Fankton Clinic, I’ankton, S. D., ad the University of South Dakota Medical School, Vermillion, S. D., and frmn the Department of Obstetrics and Gynecology, Northwestern University Medical School and of Wesley Memorial Hospital, Chicago, Ill.)
T
HERE are only twelve reported instances of cervical endometriosis in t,he literature (Fels,l Rushmore,” I’obe,” Henriques,4 Hobbs and Lazar,” Lash and Rappaport,,G Siddall and Mack,? and Navraths). It is considered to be a rare condition. We doubt, however, that this is true since we have observed sixteen such lesions and all but one during the last four years. The infrequency of reported instances of cervical endometriosis may result from lack of observation of the gross lesion because it is often quite small. Second, diagnosis depends on cervical biopsy. Many clinicians do not have cervical biopsy forceps readily available in the office and do not biopsy all abnormal-appearing areas; in other words, they are not “biopsy conscious.” Many are also hesitant to do biopsies because of the laboratory fee charged to the patient. Third, since these lesions are often small, biopsies must he accurately taken without causing trauma or crushing of the tissue; otherwise, microscopic confirmation of endometriosis may be difficult. The microscopic preparations must, therefore, be of t,he best quality and t.he individual interpreting the slides must he “ endometriosis conscious. ”
Material The sixteen instances of cervical endometriosis reported here were from patients seen by the first author and from the files of the laboratory of the D’epartment of Obstetrics and Gynecology of Northwestern University Medical School. None has been previously reported. All were located on the pars vaginalis of the cervix. Specimens from three patients were not included hecause the lesions were found only in the endocervix. Specimens from two other patients were not included because only endometrial stroma was observed; despite multiple sections, no enclometrial glands were found. All sixteen instances herein reported may be considered “primary endometriosis of the cervix” as discussed by Lash and Rappaport. This means that the reported lesions were limited to the cervix and were not extensions of endometriosis from the rectovaginal septum or from t,he serosal surface of the supravaginal portion of the cervix. In eight of our patients the cervical endometriosis produced no symptoms. The symptoms that did occur were similar to those of early cervical carcinoma, (usually premenstrual) spotting or brownish discharge i.e., intermenstrual (6 cases), postcoital bleeding (1 case), or both of these symptoms (1 case). Table I lists the gross descriptions of the endometrial lesions of the cervix as they were recorded by the various clinicians. Although the lesions were not *Presented
before
the Chicago
Gynecological 1333
Society,
Jan.
18, 1953.
RANNEY
1831
AND
Am. J. Obst. & Gynec. December, 1952
CHUNG
described in detail, there were apparent variations in the gross appearance. These variations may result from different phases of the menstrual cycle producing differing physiologic responses in the endometriotic lesion, or from different duration and/or extent of the lesion. Sk lesions were described as red, mottled areas or red, elevated, velvety areas. Two lesions appeared as small bluish nodules 2 mm. and 5 mm. in diam,eter, respectively; while another was clescribed as a 2 mm. blue “blood blister.” Another lesion was a 2 mm. superficial ulcer on the cervix. In one patient endomet,riosis was found in “friable areas on the cervix.” In two patients carcinoma of the cervix was suspected although one lesion was described as a papillomatous gr0wt.h and the other as a red mulberry 1,esion. In three patients no specific lesions of the cervix were described. IIowcver, the cndometriosis was discovered microscopically in the removed tissue. TABLE
I.
GROSS
DKWRIPTIOKS
OF LESIONS
OK THE
CERVIX
Slightly elevated, red, velvety lesion Small red circumscribed area Papillary lesion on cervix (grossly like carcinoma) Red mulberry lesion (grossly like carcinoma) 3 mm. superficial ulrer on cervix 2 mm. blue i ‘ blood blister” Bluish nodule (2 mm. and 5 mm., respectively) Few small red mottled areas Friable areas on the cervix Ko snecific lesions
Taljle 11 records the previous gynecologic operations on the sixteen patients; thirteen had had operations and twelve of the thirteen had had procedures which caused direct trauma to the cervix. Therefor,e, in seems that cervical endometriosis may result from mechanical transplantation of bits of endometrium into tenaculum holes, or into the squamous epithelium of the pars vaginalis of the cervis which has been traumatized during an operation. TARI,E
II.
HISTORY
OF PREVIOUS
GYNECOLOGIC
OPERATIVE
PF:OCEDURES
~--
__ .~~__.__~.. *All
Di!atation and curettage Cervical amput,ation Supracervical hysterectomy Cervical repair on fourth Xone were
postpartum
day
-__~--_ ____.-._
7 4 1 1 3” iFI
multiparas.
The remaining three, who gave no history of gynecologic surgery, were tnultiparas. It is possible that bits of endometrium were implanted into cervical lacerations during, or soon after delivery. This assumption is supported by the fact that implantation endometriosis is found on rare occasions in episiotomy scars. The brief history of one case is noteworthy : complained of dysmenorrhea ever Mrs. K. F., a 45year-old nulliparous white woman, since the menarrhe. She was seen by the first author on Feb. 17, 1949. Except for stenosis the genital organs were normal. On Feb. 21, and acute anterior angulation of the cervix, 1949, the cervix was widely dilated; endometrium obtained by curettement was in the proliferative phase. Menstruation was painless until September. On Sept. 13, 1949, a 3 to 3 mm. red, elevated, velvety, lesion was noted 4 mm. directly above the external OS of the cervix.
ENDOMETRIOSIS
Fig. Fig. tracheloplasty B’ig.
glands
Fig.
beneath biopsy. midsecretory
2.
the
squamous
A
epithelium.
en(lometrium.
Fig.
3.
3.-Endometriosis beneath the squamous epitheiium a cervical amputation four years prior to biopsy). Fig. 4.-High power of endometriosis from same case are in the proliferative phase. had
UTERI
Fig.
1.
l.-Endometriosis of the cervix immediately had been done three years prior to Z.-High power of Fig. 1 showing typical
Fig. patient
OF CERVIX
of portrayed
4.
the
pars in
Fig.
vaginalis 3.
(this Kote
that
1336
RANNEY
AND
CHUNG
Am. J. Ohqt. & Gym. Detember, 1952
Biopsy revealed endometrial glands and stroma in cervical tissue. One surface was covered with squamous epithelium. At one very narrow point an endometrial gland seemed to have grown through the squamous epithelium. (This may hare been the original point of perforation produced by a tenaculum on Feb. 21, 1949.)
Optimum conditions for growth of transplanted endometrium include (1) a sterile recipient site (Markee”), and (2) a moderately high estrogen blood level corresponding to that of the late proliferative phase of the menstrual an optimum cycle (Hobbs and Bortnickl”) . The vagina is never sterile,.and blood estrogen level for implantation and growth of endometrium in a new site is not of long duration. These factors probably explain why we do not see many instances of cervical endometriosis following dilatation and curettage, tracheloplasty, or trauma resulting from childbirth.
Conclusion and Summary Sixteen cases of primary endometriosis of the cervix are reported. Our experience indicates that this lesion is not so rare as it is generally thought to be. Eight of sixteen patients had no symptoms; whereas the remaining eight had intermenstrual or postcoital spotting. The gross appearance of cervical endometriosis may vary as greatly as that of pelvic endometriosis. It may resemble carcinoma. Twelve of the sixteen patients had had previous cervical operative procedures. We believe that this condition may result from transplantation of endometrial particles into punctures or lacerations of the cervix following surgical procedures, and possibly following childbirth trauma. Cervical endometriosis will be diagnosed more frequently if cervices are carefully inspected, if biopsies are taken whenever indicated, if tissues are promptly placed in fixative, and if microscopic sect,ions are carefully prepared.
References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Fels, E.: Zentralbl. f. GynHk. 52: 285, 1928. Rushmore, S.: New England J. Med. 205: 149, 1931. Fobe,. H.: Bruxelles med. 20: 626, 1940. Hennques, J.: Arq. brasil. de cir. e ortop. 9: 129, 1941. Hobbs, J. E., and Lazar, M. R.: AM. J. OBST.& GYNEC.~~: 509,1941. Lash, A. J., and Rappaport, H.: Surg., Gynec. & Obst. 77: 576, 1943. Siddall, R. S., and Mack, H. C.: AM. J. OBST. & GYNEC. 58: 765, 1949. Navrath, E.: Gynaecologia 129: 177, 1950. Markee, J. E.: Contrib. Embryol. 28: 221, 1940. Hobbs, J. E, and Bortnick, A R.: AM. J. OBST. & GYNEC. 40: 832, 1940.
Discussion DR. FRED 0. PRIEST.-We are grateful to Drs. Ranney and Chung for pointing out to us that endometriosis of the cervix occurs more%equently than we have thought it did and much more frequently than we have diagnosed it. But, when compared with the occurrence of endometriosis in its more frequent sites, primary or even secondary involvement of the The common origin of the epithelium of the tubes, corpus, cervix must be considered rare. and endoeervix makes metaplasia, under certain stimulation, a possible origin of the condition. Since experimental implantation has been so successfully carried out, then implantation of normal endometrium at the time of dilatation and curettage or of any other surgery whereby the cervix may be traumatized, or at delivery, must be considered other possibilities. Certainly the cervix, so ideally situated, is not a very receptive host or it would be the most common The absence of sterile conditions, the difference in the pH of the site of endometriosis.
Vohmle
64
.Ymlber 6
ENDOMETRIOSIS
OF
CERVIX
llTI
13x7
vagina, plus the resistance of the intact squamous epithelium of the cervix probably account Many of us may have destroyed, for the infrequency of the condition in such an ideal location. by cauterization, small implants located just beneath the epithelium of the portio. Perhaps the report this evening may stimulate US to prove by biopsy the true diagnosis of some lesions that we might otherwise destroy or cure without a diagnosis. Going through the cross index of pathology, 1941 to 1961, at the Presbyterian Hospital I found endometriosis of the cervix diagnosed in nine cases. Of these, microscopic sections were not available on three; on three others that I studied I could not diagnose primary endometriosis of the cervix because the sections were obviously taken from high in the cervix, were not covered by stratified squamous epithelium, and may have been a part of the picture of adenomyosis with secondary involvement of the cervix. So only three sections that I found really met the requirements of diagnosis. All of the sections mentioned were taken from the cervix after total hysterectomy-none from biopsy specimens. DR. A. L. LASH.-The pathogenesis is very interesting. occur more c.ommonly since there is menstrual flow occurring with a very responsive stroma.
lesions
DR. RANNEY of cervical
(Closing).-As endometriosis
have
Here every
is a lesion that month over the
Dr. Priest suggested, it is certainly been cured hy cautery or by biopsy.
possible
that
should cervix,
small
Dr. Lash’s implication, that the chief importance of this subject is to dram more careful attention to the cervix and to cervical biopsies, merits re-emphasis. Dr. Greene’s kind remark concerning the gross recognition of cervical endometriosis leads me to summarize my experience, based on the six lesions I have hiopsied: Early cervical endometriosis looks like a it blood blister. ‘9 It is bright red, velvety, slightly elevated, but covered with smooth squamous epithelium, often symmetrical, but not necessarily so. Just before, during, and just after menstruation the color of the ‘(blood blister ” may he the dark blue of “old ” blood. Later, the lesions may ulcerate or become papillary, resembling cancer, or may show brownish staining from blood pigments. Rarely is there as much scarring as is usually found in pelvic endometriosis. The average The age range of the sixteen patients, reported herein, was 35 to 60 years. age was 35.4 years. Of the sixteen patients with primary cervical endometriosis, eight had major pelvic surgery. Six of these had pelvic endometriosis, confirmed microscopically. Of the eight in whom no major pelvic surgery was performed there was clinical evidence of pelvic endometriosis in three. Thus nine of the sixteen patients with cervical endometriosis also had microscopically proved or clinically manifested endometriosis elsewhere in the pelvis. The cervix is a poor site for development of endometriosis; reasons for this have been outlined by the authors and discussants. Otherwise, many more women having cervical or vaginal surgery, or dilatation and curettage would develop cervical endometriosis. The fact that all such patients in the reproductive age group do not develop cervical endometriosis, plus the high coincidence of other endometriosis among these patients who did develop cervical endometriosis, forces us to raise this question: Have the tissues of these women some particular physiologic characteristic which especially facilitates the growth of endometriosis? Biopsies were sectioned, stained, and diagnosed in the Department of Obstetrics and Gynecology at Northwestern University Medical School.
OF THE
CERVIX
UTERI+
M.S., M.D., AND JOSEPH T. CHUNG, MS., M.D., YANKTON,
S. D.
the Department of Obstetrics and Gynecology, Fankton Clinic, I’ankton, S. D., ad the University of South Dakota Medical School, Vermillion, S. D., and frmn the Department of Obstetrics and Gynecology, Northwestern University Medical School and of Wesley Memorial Hospital, Chicago, Ill.)
T
HERE are only twelve reported instances of cervical endometriosis in t,he literature (Fels,l Rushmore,” I’obe,” Henriques,4 Hobbs and Lazar,” Lash and Rappaport,,G Siddall and Mack,? and Navraths). It is considered to be a rare condition. We doubt, however, that this is true since we have observed sixteen such lesions and all but one during the last four years. The infrequency of reported instances of cervical endometriosis may result from lack of observation of the gross lesion because it is often quite small. Second, diagnosis depends on cervical biopsy. Many clinicians do not have cervical biopsy forceps readily available in the office and do not biopsy all abnormal-appearing areas; in other words, they are not “biopsy conscious.” Many are also hesitant to do biopsies because of the laboratory fee charged to the patient. Third, since these lesions are often small, biopsies must he accurately taken without causing trauma or crushing of the tissue; otherwise, microscopic confirmation of endometriosis may be difficult. The microscopic preparations must, therefore, be of t,he best quality and t.he individual interpreting the slides must he “ endometriosis conscious. ”
Material The sixteen instances of cervical endometriosis reported here were from patients seen by the first author and from the files of the laboratory of the D’epartment of Obstetrics and Gynecology of Northwestern University Medical School. None has been previously reported. All were located on the pars vaginalis of the cervix. Specimens from three patients were not included hecause the lesions were found only in the endocervix. Specimens from two other patients were not included because only endometrial stroma was observed; despite multiple sections, no enclometrial glands were found. All sixteen instances herein reported may be considered “primary endometriosis of the cervix” as discussed by Lash and Rappaport. This means that the reported lesions were limited to the cervix and were not extensions of endometriosis from the rectovaginal septum or from t,he serosal surface of the supravaginal portion of the cervix. In eight of our patients the cervical endometriosis produced no symptoms. The symptoms that did occur were similar to those of early cervical carcinoma, (usually premenstrual) spotting or brownish discharge i.e., intermenstrual (6 cases), postcoital bleeding (1 case), or both of these symptoms (1 case). Table I lists the gross descriptions of the endometrial lesions of the cervix as they were recorded by the various clinicians. Although the lesions were not *Presented
before
the Chicago
Gynecological 1333
Society,
Jan.
18, 1953.
RANNEY
1831
AND
Am. J. Obst. & Gynec. December, 1952
CHUNG
described in detail, there were apparent variations in the gross appearance. These variations may result from different phases of the menstrual cycle producing differing physiologic responses in the endometriotic lesion, or from different duration and/or extent of the lesion. Sk lesions were described as red, mottled areas or red, elevated, velvety areas. Two lesions appeared as small bluish nodules 2 mm. and 5 mm. in diam,eter, respectively; while another was clescribed as a 2 mm. blue “blood blister.” Another lesion was a 2 mm. superficial ulcer on the cervix. In one patient endomet,riosis was found in “friable areas on the cervix.” In two patients carcinoma of the cervix was suspected although one lesion was described as a papillomatous gr0wt.h and the other as a red mulberry 1,esion. In three patients no specific lesions of the cervix were described. IIowcver, the cndometriosis was discovered microscopically in the removed tissue. TABLE
I.
GROSS
DKWRIPTIOKS
OF LESIONS
OK THE
CERVIX
Slightly elevated, red, velvety lesion Small red circumscribed area Papillary lesion on cervix (grossly like carcinoma) Red mulberry lesion (grossly like carcinoma) 3 mm. superficial ulrer on cervix 2 mm. blue i ‘ blood blister” Bluish nodule (2 mm. and 5 mm., respectively) Few small red mottled areas Friable areas on the cervix Ko snecific lesions
Taljle 11 records the previous gynecologic operations on the sixteen patients; thirteen had had operations and twelve of the thirteen had had procedures which caused direct trauma to the cervix. Therefor,e, in seems that cervical endometriosis may result from mechanical transplantation of bits of endometrium into tenaculum holes, or into the squamous epithelium of the pars vaginalis of the cervis which has been traumatized during an operation. TARI,E
II.
HISTORY
OF PREVIOUS
GYNECOLOGIC
OPERATIVE
PF:OCEDURES
~--
__ .~~__.__~.. *All
Di!atation and curettage Cervical amput,ation Supracervical hysterectomy Cervical repair on fourth Xone were
postpartum
day
-__~--_ ____.-._
7 4 1 1 3” iFI
multiparas.
The remaining three, who gave no history of gynecologic surgery, were tnultiparas. It is possible that bits of endometrium were implanted into cervical lacerations during, or soon after delivery. This assumption is supported by the fact that implantation endometriosis is found on rare occasions in episiotomy scars. The brief history of one case is noteworthy : complained of dysmenorrhea ever Mrs. K. F., a 45year-old nulliparous white woman, since the menarrhe. She was seen by the first author on Feb. 17, 1949. Except for stenosis the genital organs were normal. On Feb. 21, and acute anterior angulation of the cervix, 1949, the cervix was widely dilated; endometrium obtained by curettement was in the proliferative phase. Menstruation was painless until September. On Sept. 13, 1949, a 3 to 3 mm. red, elevated, velvety, lesion was noted 4 mm. directly above the external OS of the cervix.
ENDOMETRIOSIS
Fig. Fig. tracheloplasty B’ig.
glands
Fig.
beneath biopsy. midsecretory
2.
the
squamous
A
epithelium.
en(lometrium.
Fig.
3.
3.-Endometriosis beneath the squamous epitheiium a cervical amputation four years prior to biopsy). Fig. 4.-High power of endometriosis from same case are in the proliferative phase. had
UTERI
Fig.
1.
l.-Endometriosis of the cervix immediately had been done three years prior to Z.-High power of Fig. 1 showing typical
Fig. patient
OF CERVIX
of portrayed
4.
the
pars in
Fig.
vaginalis 3.
(this Kote
that
1336
RANNEY
AND
CHUNG
Am. J. Ohqt. & Gym. Detember, 1952
Biopsy revealed endometrial glands and stroma in cervical tissue. One surface was covered with squamous epithelium. At one very narrow point an endometrial gland seemed to have grown through the squamous epithelium. (This may hare been the original point of perforation produced by a tenaculum on Feb. 21, 1949.)
Optimum conditions for growth of transplanted endometrium include (1) a sterile recipient site (Markee”), and (2) a moderately high estrogen blood level corresponding to that of the late proliferative phase of the menstrual an optimum cycle (Hobbs and Bortnickl”) . The vagina is never sterile,.and blood estrogen level for implantation and growth of endometrium in a new site is not of long duration. These factors probably explain why we do not see many instances of cervical endometriosis following dilatation and curettage, tracheloplasty, or trauma resulting from childbirth.
Conclusion and Summary Sixteen cases of primary endometriosis of the cervix are reported. Our experience indicates that this lesion is not so rare as it is generally thought to be. Eight of sixteen patients had no symptoms; whereas the remaining eight had intermenstrual or postcoital spotting. The gross appearance of cervical endometriosis may vary as greatly as that of pelvic endometriosis. It may resemble carcinoma. Twelve of the sixteen patients had had previous cervical operative procedures. We believe that this condition may result from transplantation of endometrial particles into punctures or lacerations of the cervix following surgical procedures, and possibly following childbirth trauma. Cervical endometriosis will be diagnosed more frequently if cervices are carefully inspected, if biopsies are taken whenever indicated, if tissues are promptly placed in fixative, and if microscopic sect,ions are carefully prepared.
References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Fels, E.: Zentralbl. f. GynHk. 52: 285, 1928. Rushmore, S.: New England J. Med. 205: 149, 1931. Fobe,. H.: Bruxelles med. 20: 626, 1940. Hennques, J.: Arq. brasil. de cir. e ortop. 9: 129, 1941. Hobbs, J. E., and Lazar, M. R.: AM. J. OBST.& GYNEC.~~: 509,1941. Lash, A. J., and Rappaport, H.: Surg., Gynec. & Obst. 77: 576, 1943. Siddall, R. S., and Mack, H. C.: AM. J. OBST. & GYNEC. 58: 765, 1949. Navrath, E.: Gynaecologia 129: 177, 1950. Markee, J. E.: Contrib. Embryol. 28: 221, 1940. Hobbs, J. E, and Bortnick, A R.: AM. J. OBST. & GYNEC. 40: 832, 1940.
Discussion DR. FRED 0. PRIEST.-We are grateful to Drs. Ranney and Chung for pointing out to us that endometriosis of the cervix occurs more%equently than we have thought it did and much more frequently than we have diagnosed it. But, when compared with the occurrence of endometriosis in its more frequent sites, primary or even secondary involvement of the The common origin of the epithelium of the tubes, corpus, cervix must be considered rare. and endoeervix makes metaplasia, under certain stimulation, a possible origin of the condition. Since experimental implantation has been so successfully carried out, then implantation of normal endometrium at the time of dilatation and curettage or of any other surgery whereby the cervix may be traumatized, or at delivery, must be considered other possibilities. Certainly the cervix, so ideally situated, is not a very receptive host or it would be the most common The absence of sterile conditions, the difference in the pH of the site of endometriosis.
Vohmle
64
.Ymlber 6
ENDOMETRIOSIS
OF
CERVIX
llTI
13x7
vagina, plus the resistance of the intact squamous epithelium of the cervix probably account Many of us may have destroyed, for the infrequency of the condition in such an ideal location. by cauterization, small implants located just beneath the epithelium of the portio. Perhaps the report this evening may stimulate US to prove by biopsy the true diagnosis of some lesions that we might otherwise destroy or cure without a diagnosis. Going through the cross index of pathology, 1941 to 1961, at the Presbyterian Hospital I found endometriosis of the cervix diagnosed in nine cases. Of these, microscopic sections were not available on three; on three others that I studied I could not diagnose primary endometriosis of the cervix because the sections were obviously taken from high in the cervix, were not covered by stratified squamous epithelium, and may have been a part of the picture of adenomyosis with secondary involvement of the cervix. So only three sections that I found really met the requirements of diagnosis. All of the sections mentioned were taken from the cervix after total hysterectomy-none from biopsy specimens. DR. A. L. LASH.-The pathogenesis is very interesting. occur more c.ommonly since there is menstrual flow occurring with a very responsive stroma.
lesions
DR. RANNEY of cervical
(Closing).-As endometriosis
have
Here every
is a lesion that month over the
Dr. Priest suggested, it is certainly been cured hy cautery or by biopsy.
possible
that
should cervix,
small
Dr. Lash’s implication, that the chief importance of this subject is to dram more careful attention to the cervix and to cervical biopsies, merits re-emphasis. Dr. Greene’s kind remark concerning the gross recognition of cervical endometriosis leads me to summarize my experience, based on the six lesions I have hiopsied: Early cervical endometriosis looks like a it blood blister. ‘9 It is bright red, velvety, slightly elevated, but covered with smooth squamous epithelium, often symmetrical, but not necessarily so. Just before, during, and just after menstruation the color of the ‘(blood blister ” may he the dark blue of “old ” blood. Later, the lesions may ulcerate or become papillary, resembling cancer, or may show brownish staining from blood pigments. Rarely is there as much scarring as is usually found in pelvic endometriosis. The average The age range of the sixteen patients, reported herein, was 35 to 60 years. age was 35.4 years. Of the sixteen patients with primary cervical endometriosis, eight had major pelvic surgery. Six of these had pelvic endometriosis, confirmed microscopically. Of the eight in whom no major pelvic surgery was performed there was clinical evidence of pelvic endometriosis in three. Thus nine of the sixteen patients with cervical endometriosis also had microscopically proved or clinically manifested endometriosis elsewhere in the pelvis. The cervix is a poor site for development of endometriosis; reasons for this have been outlined by the authors and discussants. Otherwise, many more women having cervical or vaginal surgery, or dilatation and curettage would develop cervical endometriosis. The fact that all such patients in the reproductive age group do not develop cervical endometriosis, plus the high coincidence of other endometriosis among these patients who did develop cervical endometriosis, forces us to raise this question: Have the tissues of these women some particular physiologic characteristic which especially facilitates the growth of endometriosis? Biopsies were sectioned, stained, and diagnosed in the Department of Obstetrics and Gynecology at Northwestern University Medical School.