(44) Eliciting a Targeted Patient History to Inform a Diagnosis of a Müllerian Anomaly

Background: Müllerian anomalies occur when there is a duplication or failure to fuse of the müllerian ducts. These structural anomalies may be elucidated on imaging, but asking specific, directed questions to elicit a thorough patient history is important to identify the correct diagnosis and effective treatment of the patient’s condition(s).

Case: A 17 year old post-menarchal patient presented for evaluation of a known anomaly of the reproductive tract. An MRI showed uterine didelphys, two cervices, and duplicated non-obstructed hemivaginas, with the left cervix 6-7 mm superior to the level of the right cervix. Her physical exams by multiple experienced gynecologists yielded evidence of a single vaginal opening and single cervix, supporting the diagnosis of a left obstructed hemivagina with a microperforation which permitted drainage of menstrual blood, or a small communication between the two cervices. She was not experiencing dyspareunia, had no pelvic pain, and her menses were suppressed using norethindrone acetate until the patient was ready for surgery. Over the next several years, the patient complained of abnormal discharge and experienced recurrent yeast infections. While planning surgery at age 22 and discussing ongoing symptoms, the patient shared that before beginning menstrual suppression, she experienced leakage around tampons and the blood was always on the left side of her underwear. On physical exam, a small left vaginal opening was identified in addition to the much larger right vagina, confirming a diagnosis of longitudinal vaginal septum.

Comments: Although longitudinal vaginal septum was a suspected diagnosis at the initiation of the patient’s care based on imaging, the left hemivagina was not found on physical exam due to significant asymmetry of the duplex vaginal canals. The patient’s response to a targeted set of probing questions and thoughtful consideration of the patient’s symptoms helped direct the gynecologic physical exam, thereby providing the appropriate diagnosis and treatment of this patient with a müllerian anomaly.