A 36-year-old woman with endometriosis, pelvic pain, and infertility.

Abstract

DR DALEY: MS B IS A 36-YEAR-OLD MARRIED MEDICAL WRITER with pelvic pain, endometriosis, and infertility. She lives near Boston with her husband and 1-year-old adopted daughter. She has managed care insurance. Ms B experienced menarche at age 12 years. She reports moderate-to-severe dysmenorrhea for many years, intermittent abdominal cramping, diarrhea, “gas,” and occasional urinary urgency and frequency. In 1994, she attempted pregnancy. Several months later, she was hospitalized with severe pelvic pain and a large ovarian mass. Laparoscopic surgery revealed a large (8-10 cm) ruptured hemorrhagic ovarian mass consistent with an endometrioma. The cyst was removed laparoscopically, and Ms B began treatment with leuprolide acetate (Lupron Depot). She experienced adverse effects including hot flashes and fatigue. During leuprolide therapy, the endometrioma recurred, and she underwent a second laparoscopic endometriomectomy. Ms B sought a second opinion and had a hysterosalpingogram that demonstrated normal uterus, patent fallopian tubes, and scarred fimbria. A laparotomy showed “severe endometriosis” with extensive pelvic scarring and adhesions. Ms B declined another course of leuprolide therapy because of previous adverse effects. She began acupuncture and herbal treatments. Ms B and her husband attempted again to conceive, unsuccessfully. A transvaginal ultrasound revealed another endometrioma on the other ovary. She then underwent 2 unsuccessful cycles of in vitro fertilization. While Ms B and her husband were considering further therapy for infertility, a family member became pregnant, and the opportunity for an in-family adoption became available. She and her husband adopted a healthy baby girl in 1997. In April 1998, Ms B had recurrent severe dysmenorrhea and worsening pelvic pain that became progressively disabling and finally acute. Examination revealed a ruptured endometrioma, which was managed with pain medication and bed rest. She began oral contraceptives, and her symptoms decreased. Adverse effects included occasional mild headaches and occasional midcycle spotting. She currently has moderate dysmenorrhea for which she takes nonsteroidal antiinflammatory agents (NSAIDs), but she has no symptoms between her menstrual cycles. She is considering having another child and is wondering whether she should discontinue oral contraceptives to attempt pregnancy, attempt conception with assisted reproductive technologies, or pursue another adoption. Past medical history is significant for hypothyroidism, rosacea, and mild gastroesophageal reflux disease. Current medications include metronidazole topical gel (MetroGel), levothyroxine sodium (Synthroid), 100 μg/d, and ethinyl estradiol– norethindrone (Ortho-Novum 7/7/7). She also takes a calcium supplement, a multivitamin, and vitamin E. She does not smoke and drinks 3 to 4 glasses of beer or wine per week. Family history is significant for coronary artery disease. Ms B is concerned that her sister may also have endometriosis. Recent physical examination revealed a healthy woman. Vital signs were stable. Breast examination findings were normal. On pelvic examination, external genitalia, vagina, and uterus were normal. The adnexa were nontender and no masses were palpated. A Papanicolaou test showed no malignant cells. Pelvic ultrasound showed a complex ovarian cyst measuring 1.7 cm in diameter, slightly decreased in size from an ultrasound 3 months earlier.