Background Retroperitoneal ectopic pregnancy (REP) is an extremely rare type of ectopic pregnancy, with a total of less than 32 cases reported in the English literature. Early diagnosis of REP is very difficult and all treatments entail a high risk of life-threatening complications. Case presentation A 29-year-old nulliparous woman presented a history of 50-day amenorrhea and 7-day upper abdominal pain without vaginal spotting. The serum beta-human chorionic gonadotropin (β-hCG) value was 65,004 m-international units per milliliter (mIU/mL), but no intrauterine gestational sac was found via transvaginal sonography (TVS). Then transabdominal ultrasonography (TAS) and abdominal contrast-enhanced computer tomography (CT) identified a retroperitoneal ectopic pregnancy (REP) tightly adjacent to the inferior vena cava and the abdominal aorta. After consultation from a multidisciplinary team, systemic methotrexate (MTX, intramuscular 20 mg daily for 5 consecutive days) combined with ultrasound-guided local potassium chloride solution injection into the gestational sac was scheduled firstly for the patient. However, serum β-hCG continued to increase and the patient experienced worsening abdominal pain. Laparotomy was performed jointly by a gynecologist and a vascular surgeon. During the operation, the gestational sac with fetal bud measuring about 4.5 × 4.0x3.0 cm, tightly adherent to the surface of inferior vena cava and the left side of abdominal aorta, was carefully dissociated out from the surrounding tissues and removed en bloc. Histopathology examination confirmed the diagnosis of REP. The patient recovered uneventfully and her serum β-hCG returned to normal range on the 23th postoperative day. Conclusions Considering the possibility of REP and combined radiological examinations, such as ultrasonography and CT, are crucial for the early diagnosis of this rare condition. A multidisciplinary team is necessary to treat REP.

Background: Postmenopausal bleeding (PMB) is a common gynecologic complaint among elderly women, and endometrial hyperplasia is a common cause of this bleeding. Ovarian fibromas are the most common ovarian sex cord stromal tumors (SCST). They arise from non-functioning stroma, rarely show estrogenic activity, and stimulate endometrial hyperplasia, leading to abnormal vaginal bleeding. Case presentation: We report herein the case of a 64-year-old Chinese woman who presented with recurrent PMB. A sex-hormone test revealed her estrogen level was significantly higher than normal, and other causes of hyperestrogenism had been excluded. In the past 7 years, the patient had undergone four curettage-and-hysteroscopy procedures due to recurrent PMB and endometrial hyperplasia. Finally, the culprit behind the rise in estrogen – an ovarian cellular fibroma with estrogenic activity – was found in the fifth operation.Conclusions: Ovarian cellular fibromas occur insidiously, and some may have endocrine functions. For postmenopausal patients with recurrent PMB and endometrial thickening indicated by ultrasonography, it is recommended they undergo sex-hormone testing while waiting for results regarding the pathology of the endometrium. If the estrogen level remains elevated, even if the imaging does not indicate an ovarian tumor, the clinician should consider the possibility of an ovarian SCST and follow the patient closely. Once the tumor is found, no matter the size, it should be removed as soon as possible to avoid endometrial lesions caused by long-term estrogen stimulation. More studies are needed to confirm whether preventive total hysterectomy with bilateral salpingo-oophorectomy should be recommended for postmenopausal women with recurrent bleeding whose estrogen levels are higher than normal, even when the auxiliary examination does not indicate ovarian mass. It is possible this could avoid the physical and psychological burden caused by repeated curettage.

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