Reproductive · Year 2 · from Reproductive
Case 2: Endometriosis
Clinical Image
Source: Wikipedia - Endometriosis - CC BY-SA 4.0
Case Presentation
A 31-year-old nulligravid woman presents with a 6-year history of progressively worsening dysmenorrhea. Her menstrual pain begins 2 days before the onset of bleeding and continues for the first 3 days of her period, requiring her to miss work 1-2 days per month despite using maximum doses of NSAIDs. She also reports deep dyspareunia and dyschezia (painful bowel movements) that worsens perimenstrually. She and her husband have been attempting pregnancy for 2 years without success. Physical examination reveals a fixed, retroverted uterus and tender nodularity along the uterosacral ligaments palpable on rectovaginal exam. Transvaginal ultrasound shows a 4 cm left ovarian cyst with homogeneous low-level echoes (ground-glass appearance) consistent with an endometrioma. CA-125 is mildly elevated at 58 U/mL. Given her symptoms, examination findings, and infertility, diagnostic and therapeutic laparoscopy is performed. At surgery, stage III endometriosis is found with extensive adhesions, blue-black "powder burn" lesions on the peritoneum, and left ovarian endometrioma. Lesions are excised, adhesions are lysed, and the endometrioma is carefully removed with ovarian preservation. Postoperatively, she conceives naturally within 6 months.
Key Learning Points
- Endometriosis is defined by endometrial glands and stroma outside the uterus; the classic triad is dysmenorrhea, dyspareunia, and infertility
- Physical exam findings suggestive of endometriosis include fixed retroverted uterus (from adhesions), tender uterosacral nodularity, and adnexal masses (endometriomas)
- Endometriomas appear as "chocolate cysts" with homogeneous low-level echoes (ground-glass) on ultrasound
- Laparoscopy remains the gold standard for diagnosis and allows concurrent surgical treatment; excision may improve fertility in moderate-severe disease