Review Question - QID 221288

This patient, who presents with cyclic dysmenorrhea, dyspareunia, and dyschezia that is worse during menstruation, most likely has endometriosis. The most appropriate next steps in the management of endometriosis are nonsteroidal anti-inflammatory drugs and combined oral contraceptives.

Endometriosis is a condition in which endometrium-like tissue forms glands and functional stroma outside of the uterus. The most frequent sites of colonization include the ovaries, pelvis, and peritoneum. Patients typically present with cyclic pelvic and sometimes rectal pain, dysmenorrhea, dyspareunia, and dyschezia. In the ovaries, the tissue may be present as endometriomas or "chocolate cysts," which may sometimes be palpated on physical exam. The uterus is usually not enlarged, but painful nodules or a restricted range of motion may be noted on exam. If endometrial tissue is present on the uterosacral ligaments, the rectal exam may also produce pain. An ultrasound and pregnancy test should be performed as part of the initial workup. First-line treatment includes NSAIDs and combined OCPs in order to relieve pain and to decrease hormone stimulation of the extra-uterine endometrial tissue that causes the pain.

Sandstrom et al. studied the efficacy of hysterectomy in relieving pain due to endometriosis. They found that most patients report improvement in pain after hysterectomy regardless of concurrent oophorectomy. They recommend further study if hormonal suppression with progestins or continuous combined OCPs further reduces pain.

Figure/Illustration A is an ultrasound demonstrating an ectopic lesion inside the pelvis (red circle). This finding is consistent with a diagnosis of endometriosis.

Incorrect Answers:
Answer 1: Hysterectomy would not be the most appropriate initial treatment for endometriosis. This definitive surgical treatment should be reserved after all other methods of management have failed. If the endometriosis is severe enough to warrant definitive surgical treatment, the surgery would usually be a total abdominal hysterectomy with bilateral salpingo-oopherectomy.

Answer 2: Laparoscopy would be the method of definitively diagnosing endometriosis, but treatment via laparoscopic excision, ablation, or cauterization of extra-uterine endometrial tissue would only be pursued after medical management has failed. On laparoscopy, lesions typically have a blue-black or dark brown appearance.

Answer 3: Leuprolide is a gonadotropin-releasing-hormone agonist that suppresses the release of luteinizing hormone and follicle-stimulating hormone. This change subsequently decreases levels of estrogen and progesterone that stimulate the extra-uterine endometrial tissue. It is often used in the treatment of endometriosis, but would be considered after NSAIDs and combined OCPs have already been trialed.

Answer 5: Uterine artery embolization is a treatment for uterine fibroids that cause dysmenorrhea or menorrhagia. It is not effective as a treatment for endometriosis.

Bullet Summary:
Endometriosis should be treated with nonsteroidal anti-inflammatory drugs and either continuous hormonal contraceptives or progestin-only pills.