A Mother of Four With Menstruation Issues and Debilitating Pain

Linda A. Dultz, MD, MPH; Karina L. Vivar; Suzanne MacFarland; MaryAnn Hopkins, MD, MPhil


January 17, 2023

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to recognize accurately. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 38-year-old woman presents with a 2-year history of an abdominal wall mass that has recently enlarged in size. She reports unusual sensations of soreness and pain in her abdomen associated with the mass. The symptoms are predominantly premenstrual and have progressed to the point of debilitation. She has not noticed any other masses or lesions on her body. Three years prior to presentation, the patient began experiencing menorrhagia and dysmenorrhea.

The patient's gynecologic history is significant for menarche at age 10 years, an elective abortion at age 18 years, and an ectopic pregnancy treated by left salpingectomy at age 25 years. She has never taken hormonal contraception. She underwent ovarian stimulation and uterine preparation for in vitro fertilization (IVF) at age 25 years. The patient received leuprolide prior to ovarian stimulation; she also received progesterone to ameliorate menopausal symptoms associated with leuprolide. Ovarian stimulation was achieved and was followed by successful egg retrieval. The patient later had 4 transvaginal IVF embryo transfers, resulting in 3 pregnancies and 4 children. Her first 2 children were born via normal spontaneous vaginal deliveries when the patient was aged 26 years and 28 years. At age 30 years, she gave birth to twins, one via normal spontaneous vaginal delivery and the other via cesarean delivery because of failure to progress. No unusual findings were noted at the time of cesarean delivery.

The patient has had no other surgeries. She has no other significant medical history. She does not have any allergies and, at presentation, she is not on any medications. She has not had any recent weight loss, fevers, or chills.


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