Review Question - QID 218779

This patient presenting with dysmenorrhea, menorrhagia, dyschezia, and infertility (inability to conceive after 1 year) most likely has endometriosis.

Endometriosis is thought to be caused by retrograde menstruation (with many different theories) with ectopic implantation of endometrial cells in the uterine tubes and peritoneal cavity. This ectopic endometrial tissue is hormone-responsive, causing dysmenorrhea and menorrhagia. Symptoms of endometriosis can vary widely depending on the site of implantation of tissue. Peritoneal or cervical lesions can cause dyspareunia, bladder implants can cause urinary frequency or urgency, bowel implants can cause diarrhea or constipation, rectovaginal ligament implants cause dyschezia, and abdominal wall implants can cause abdominal pain. Infertility is also a possible finding in endometriosis. Transvaginal ultrasound may reveal lesions in this condition. The gold standard for diagnosis is laparoscopy with biopsy; however, an empiric diagnosis is often made in women with classic symptoms. Treatment is initially with non-steroidal anti-inflammatory medications such as ibuprofen and combined oral contraceptives. Surgical treatment via resection or ablation is reserved for cases refractory to conservative treatment.

Vercellini et al. reviewed the pathogenesis and treatment of endometriosis. The authors found that endometriosis is associated with an increased risk of ovarian cancer. They recommended that treatment be tailored to patient needs and symptoms.

Incorrect Answers:
Answer 1: Adenomyosis is characterized by the implantation of endometrial tissue into the myometrium, presenting with dysmenorrhea and menorrhagia. Physical examination typically discloses a soft, globular uterus that is uniformly enlarged. In contrast, this patient has a normal sized uterus. It is important to note that most patients with endometriosis also have adenomyosis. Note that this patient has extra-uterine symptoms including a tender adnexal mass supporting a diagnosis of endometriosis rather than only adenomyosis. A definitive diagnosis of endometriosis can only be made histologically after examination of a hysterectomy (hysterectomy is the definitive treatment).

Answer 3: Ovarian torsion is caused by a twisting of the ovary around its suspensory ligament. Patients with ovarian torsion present with sudden severe abdominal pain, nausea, vomiting, and absence of ovarian blood flow on Doppler ultrasound. In premenopausal patients with a viable ovary, surgical detorsion is the treatment of choice. In patients with a necrotic ovary or postmenopausal patients, salpingo-oophorectomy is pursued.

Answer 4: Pelvic inflammatory disease is characterized by lower abdominal pain, cervical motion tenderness, and cervical or vaginal discharge. Progression of this disease can lead to perihepatitis (Fitz-Hugh-Curtis syndrome) with right upper quadrant pain. Pelvic inflammatory disease is a progression of a sexually-transmitted infection and should be treated promptly with antibiotics, including ceftriaxone, doxycycline (in non-pregnant patients), and metronidazole to cover for the common pathogens of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas.

Answer 5: Uterine fibroids, or leiomyomas, are benign growths of smooth muscle cells in the uterus, leading to menorrhagia, dysmenorrhea, possibly pelvic pain, and infertility. Physical exam may disclose an irregularly shaped, firm, lumpy uterus. Pain is not common in leiomyomas. The diagnosis can be made with an ultrasound showing the fibroid(s) and treatment for symptomatic fibroids that are accessible through the uterine cavity is with myomectomy.

Bullet Summary:
Endometriosis refers to the ectopic implantation of endometrial tissue and can present with dysmenorrhea, menorrhagia, dyschezia, urinary urgency or frequency, diarrhea, constipation, and abdominal pain.