This patient's signs and symptoms are consistent with endometriosis . A definitive diagnosis of endometriosis requires laparoscopic examination with biopsy.
Endometriosis is a benign condition that occurs when endometrial glands and stroma are located outside of the uterus, most commonly on the ovaries, the uterosacral and broad ligaments, and the cul de sac (Illustration A). Endometriosis classically presents with dysmenorrhea, dyspareunia, dyschezia, and infertility. The classic endoscopic finding of endometriosis is a chocolate cyst, which is a large implant on the ovary that is filled with blood (Illustration B). Both medical treatments (NSAIDS, OCPs, GNRH agonists) and surgical treatments (laparoscopic ablation and total abdominal hysterectomy) are available.
Schrager et al. review the evaluation and treatment of endometriosis. While it is only present in approximately 10% of reproductive age women, the prevalence of endometriosis rises dramatically in those with pelvic pain (70-90%) and infertility (21-40%). There are core signs and symptoms that are descriptive of endometriosis; however, the presentation and severity can vary significantly from patient to patient.
Fadhlaoui et al. review the treatment options for improving fertility in endometriosis. Endometriosis is thought to be associated with increased rate of infertility through a variety of different mechanisms. They discuss the current debate between medical and surgical treatment options for infertility. While medical treatments may be used to control the disease, it has not been shown to increase fertility. On the other hand, studies have found evidence that surgery is beneficial in improving spontaneous pregnancy rates in minimal or mild endometriosis.
Illustration A demonstrates common locations for endometrial implants. Illustration B shows a ruptured chocolate cyst, which is a blood filled endometrial implant on the ovary. Illustration C depicts an endometrial implant on the pouch of Douglas. Illustration D demonstrates a large endometriotic cyst, or endometrioma, as seen via transvaginal ultrasonography.
Answer 1: CT scan does not provide a definitive diagnosis for endometriosis.
Answer 3: MRI scan does not provide a definitive diagnosis for endometriosis.
Answer 4: Endometrial biopsy does not provide a definitive diagnosis for endometriosis.
Answer 5: Transvaginal ultrasonography may be useful in identifying large endometriotic cysts; however, it does not provide a definitive diagnosis.
Schrager S, Falleroni J, Edgoose J. Evaluation and treatment of endometriosis. Am Fam Physician. 2013 Jan 15;87(2):107-13. PubMed PMID: 23317074.
PMID:23317074 (Link to Abstract)
Fadhlaoui A, Bouquet de la Jolinière J, Feki A. Endometriosis and infertility: how and when to treat? Front Surg. 2014 Jul 2;1:24. doi: 10.3389/fsurg.2014.00024. eCollection 2014. Review. PubMed PMID: 25593948
PMID:25593948 (Link to Abstract)