Endometriosis

Patient Presentation
MM, a 17 y/o female presents to the OB/GYN office complaining of severe menstrual cramps that start 2 days before menstruation and last until 2-3 days after bleeding has ceased. She recalls her very first period being painful. She describes the cramps as intense, 9/10 pain; it has caused her to miss some school because she has a hard time concentrating or getting out of bed. Cramps are unrelieved by around-the-clock ibuprofen. Her periods have been painful since she began menstruating at age 15 and have gotten progressively worse. She has been sexually active since age 16 with one male partner and experiences occasional pain with sex (dyspareunia).

Differential List
Pelvic Inflammatory Disease (PID), Endometriosis, Adenomyosis, Cystitis

Diagnosis
External and internal vaginal exams are normal
CBC normal except for mild anemia
Transvaginal and pelvic ultrasounds are ordered and show the following:
Treatment
Endometriosis is the suspected diagnosis but can only be definitively diagnosed through surgical visualization of the reproductive organs. The patient undergoes a laparoscopic procedure where the surgeon is able to examine the uterus and ovaries. Surgery reveals many reddened “spots” of endometrium on the uterus, fallopian tubes, and ovaries. The surgeon used laser vaporization to burn several of these endometrial implants on the outer surface of the reproductive organs. The diagnosis was definitively made as endometriosis. In this case, a likely diagnosis of adenomyosis was also made after verification of a heavy, “boggy” uterus indicative of endometrial tissue growing within the walls of the uterus.

Outcome
Post-operatively, the patient was put on a combined oral contraceptive (COC) to be taken continuously to suppress menstruation which in turn suppresses the growth of endometriosis. She experienced a significant decrease in pelvic pain after the surgery and will remain on a COC until she desires pregnancy.

More Info on Endometriosis and Adenomyosis
Endometriosis is a condition in which endometrial tissue become implanted outside the uterus. It is a very common disease, affecting 1 in 10 women during their reproductive years. Fifty percent of women with endometriosis have no symptoms. It only becomes problematic when it causes pain or scarring severe enough to cause infertility. Endometriosis has the potential of traveling anywhere in the body (bladder, vaginal walls, skin, and even the lungs, spine, and brain). The most common treatment option is COCs taken continuously (without the hormone free interval). Other hormonal treatments are progestins, Mirena® IUD, GnRH analogues (Lupron®), Danazol®, aromatase inhibitors. Surgical treatments include laparoscopy with laser vaporization, excision of endometrial implants, or hysterectomy.

Adenomyosis is different from endometriosis in that the endometrium grows within the walls of the uterus. Many women who have this condition also have endometriosis.