A 38-Year-Old Woman With Debilitating Premenstrual Pain

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

Disclosures

July 26, 2019

The mainstay of treatment for endometriosis includes medical and/or surgical treatment.[6] Medical therapies consist most commonly of the use of nonsteroidal anti-inflammatory drugs (NSAIDs), progestogens, oral contraceptive pills, or gonadotropin-releasing hormone (GnRH) agonists. Sustained progestins work by atrophying the glands, while GnRH analogs suppress endogenous estrogen.

Surgical procedures can also be performed, either as first-line management or when patients are refractory to medical therapy. Treatment options may include laparoscopic or open excision with fulguration, or laser ablation of endometriosis, resection of rectovaginal nodules, lysis of adhesions, and/or interruption of nerve pathways to obtain pain relief.[21] Recurrence of symptoms is common in up to 60% of patients despite surgical efforts, and postoperative medical therapy is normally continued with a GnRH agonist, danazol, or combined oral contraceptives.[21]

The role of IVF leading to worsening of endometriosis is currently under investigation and is controversial in nature. Whether ovarian stimulation leads to progression of disease in these patients due to the unopposed estrogen is unclear. Several case reports and retrospective studies have presented data for both sides of the argument.[22,23,24,25] In a review article by Dechaud and colleagues,[26] the authors conceded that more data need to be obtained to conclusively determine whether IVF plays a role in the worsening of endometriosis.

In this case, the patient had no known history of pelvic endometriosis, but because her symptoms increased with her menstrual cycles, the diagnosis could be suspected prior to surgery. The patient underwent surgery without complications and was discharged to home the same day. She has done well postoperatively and remains pain-free. Because she had an isolated nodule and has not had any return of her pain symptoms, she remains off medical therapy.

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