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LEARNING OBJECTIVES

  1. Identify the signs, symptoms, and diagnostic criteria for endometriosis.

  2. Explain the pharmacologic basis for hormonal therapies for endometriosis.

  3. Compare and contrast the advantages and disadvantages of each medication used to treat endometriosis.

  4. Develop a comprehensive plan for a patient with symptomatic endometriosis consistent with the patient’s goals.

  5. Educate a patient with endometriosis including important patient counseling points.

INTRODUCTION

Endometriosis is one of the most common gynecological diseases, and is defined as the growth of endometrial-like tissue outside of the uterus. An endometrioma is a cystic mass that forms from ectopic endometrial tissue within the ovary. Endometriomas contain a thick, brown, tar-like fluid, and often adhere to surrounding structures including the peritoneum, fallopian tubes, and bowel.

Endometriosis mainly occurs during the reproductive years and is most commonly diagnosed in patients 30 to 50 years old; however, the condition can affect any patient who menstruates.1 Epidemiology is difficult to determine since many patients with the condition can be asymptomatic. Roughly 1 in 10 patients of reproductive age is diagnosed with endometriosis,1 and conservatively, it is estimated that 11% go undiagnosed.2 The prevalence is higher in certain populations, occurring in 38% of infertile women and 71% to 87% of women with chronic pelvic pain.3 A familial association exists for endometriosis diagnosis, and patients with an affected first-degree relative have a seven- to tenfold increased risk of also developing endometriosis.3 The most common symptoms causing patients to seek care are dysmenorrhea, chronic pelvic pain, dyspareunia, menstrual-related or cyclical gastrointestinal symptoms and/or urinary symptoms; with infertility associated with at least one of the these symptoms.

Patient Case (Part 1)

D.F. is a 23-year-old, single woman who presents to the outpatient obstetrics and gynecology clinic.

Chief Concern: “Intensity of my pelvic cramping has increased and expanded into lower back. The pain is awful. I have painful cramps lasting 1-3 days each cycle.”

History of Present Illness: 2 year history of moderate to severe lower pelvic cramps and heavy blood flow that lasts for about a day each cycle, which has been treated with ibuprofen for the last several years. The pain is significant enough to cause her to miss 1-2 days of work per month. She has tried ibuprofen for the pain, which has provided minimal relief.

Medical History: None significant

Family History: Mother—no history of endometriosis

Social History: Denies tobacco or alcohol use

Medications:

  • Multivitamin daily

  • Ibuprofen 400 mg every 4 hours as needed for dysmenorrhea

Reproductive History: Menarche was at age 12 years. Regular menstrual cycle lasting 28-30 days

Sexual History: Not currently sexually active and not desiring conception

Vital Signs: Blood pressure 122/78 mm Hg, heart rate 72 beats per minute, respiratory rate 16 breathes per minute, temperature 98.6°F

Measurements: Body mass index 24 kg/m2

Physical Examination: Unremarkable; breast examination normal. On pelvic examination, uterus was palpable on a retroverted position; pelvic tenderness and enlarged ...

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