A 32-year-old woman, gravida 3 para 3, comes to the office for a 2-week postoperative follow-up after undergoing a laparoscopic bilateral tubal ligation. The patient has no pain or abnormal discharge from the incision sites. She has no chronic medical conditions, and this was her only surgery. The patient has a regular menstrual period that occurs every 30 days. She typically has abdominal cramping that resolves with ibuprofen after the first day and 5 days of bleeding. The tubal ligation was successfully performed; however, during the procedure, multiple subcentimeter, superficial lesions were visualized over the broad ligaments, bladder, and sigmoid colon. Biopsy of a lesion reveals endometrial glands, stroma, and hemosiderin-laden macrophages. Which of the following is the best next step in management of this patient?

Question

A 32-year-old woman, gravida 3 para 3, comes to the office for a 2-week postoperative follow-up after undergoing a laparoscopic bilateral tubal ligation.  The patient has no pain or abnormal discharge from the incision sites.  She has no chronic medical conditions, and this was her only surgery.  The patient has a regular menstrual period that occurs every 30 days.  She typically has abdominal cramping that resolves with ibuprofen after the first day and 5 days of bleeding.  The tubal ligation was successfully performed; however, during the procedure, multiple subcentimeter, superficial lesions were visualized over the broad ligaments, bladder, and sigmoid colon.  Biopsy of a lesion reveals endometrial glands, stroma, and hemosiderin-laden macrophages.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d9c0_546b_bc81_0f4d68237cf0_MD0003_00 This patient with multiple intraabdominal lesions revealing endometrial glands, stroma, and hemosiderin-laden macrophages most likely has endometriosis, or ectopic implants of endometrial tissue in the abdomen and pelvis. Endometriosis may occur due to a combination of cellular metaplasia and retrograde menstruation into the peritoneal cavity. Endometriosis implants, like normal endometrium, proliferate and shed in response to pulsatile estrogen and progesterone. This cyclic shedding without an outlet can cause chronic intraperitoneal inflammation, pain, and fibrosis. However, some patients are asymptomatic and diagnosed incidentally during an unrelated surgery (eg, this patient during tubal ligation). endometrial glands, stroma, and hemosiderin-laden macrophages Indications for treatment of endometriosis include: Chronic pelvic pain Dysmenorrhea, or increasingly worse lower abdominal cramping throughout menses, that is unrelieved by nonsteroidal anti-inflammatory drugs Dyspareunia Infertility (eg, due to pelvic adhesions) In contrast, those with asymptomatic endometriosis, including this patient who has minimal menstrual cramping and no longer desires fertility (eg, tubal ligation), require reassurance and observation only. (Choice A) Combined oral contraceptives can treat symptomatic endometriosis by suppressing ovarian function, thereby decreasing pulsatile stimulation of ectopic implants and resultant intraabdominal inflammation and pain. This patient has adequate pain relief with ibuprofen during menses and does not require contraception given her recent tubal ligation. (Choice B) Diagnosis of endometriosis is either clinical (based on symptoms) or via biopsy during laparoscopy, as in this patient. Endometriosis is typically a benign condition and does not require further imaging (eg, CT scan) for evaluation or treatment. (Choice C) GnRH agonists (eg, leuprolide) can treat symptomatic endometriosis by acting on the pituitary to decrease pulsatile FSH and LH release, thereby decreasing stimulation of ectopic implants and relieving pain. However, they are not recommended for asymptomatic patients because the adverse side effects (eg, decreased bone density from hypoestrogenism) outweigh the benefits. (Choice E) Surgical resection of endometriosis may reduce pain and improve fertility in symptomatic patients, but is not recommended for asymptomatic patients due to unnecessary surgical risk. Educational objective: Endometriosis is the ectopic implant of endometrial tissue in the abdomen and pelvis, which may cause chronic inflammation, pain, and fibrosis. Indications for treatment include chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility. Patients with asymptomatic endometriosis require observation and reassurance only. References: Clinical presentation of endometriosis identified at interval laparoscopic tubal sterilization: prospective series of 465 cases. (http://www.ncbi.nlm.nih.gov/pubmed/28526518) Introduction: management of endometriosis: moving toward a problem-oriented and patient-centered approach. (http://www.ncbi.nlm.nih.gov/pubmed/26363383)

A 32-Year-Old Woman, Gravida 3 Para 3, Comes to the Office