A 22-year-old woman comes to the office with right lower quadrant pain for the past 3 weeks. The pain is exacerbated with bowel movements, but there is no associated nausea, vomiting, diarrhea, constipation, or melena. She has no chronic medical conditions and has never had surgery. Family history is noncontributory. The patient has regular menstrual periods every 28-30 days. She is sexually active and uses condoms for contraception. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, and pulse is 80/min. BMI is 24 kg/m². Physical examination shows a well-appearing woman in no apparent distress. The abdomen is soft with normal bowel sounds. There is tenderness to deep palpation in the right lower quadrant without rebound or guarding. The uterus is small, nontender, and anteverted; there is no cervical discharge or cervical motion tenderness. The right adnexa is enlarged and tender. There is nodularity and tenderness on rectovaginal examination. This patient is at increased risk for which of the following conditions?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_bef5_25dc_8f63_45af819a26e7_MD0005_00 This patient has pelvic pain with exacerbation by bowel movements (dyschezia) and rectovaginal nodularity on pelvic examination, classic findings of endometriosis. Endometriosis is an extrauterine implantation of endometrial tissue that causes inflammation and fibrosis as implants cyclically shed in the ectopic location. The most frequent sites of involvement are the ovaries, cul-de-sac, broad ligaments, uterosacral ligaments, fallopian tubes, and sigmoid colon. Ovarian involvement typically presents with unilateral pelvic pain and a tender adnexal mass (eg, endometrioma). Endometriosis causes pelvic adhesions and inflammation, which can cause infertility and chronic pelvic pain. Treatment is with nonsteroidal anti-inflammatory drugs, oral contraceptives, GnRH agonists, or surgical resection. Infertility due to endometriosis is treated with surgical resection or in vitro fertilization. extrauterine implantation (Choice A) Cervical dysplasia is caused by human papillomavirus (HPV); infection is typically asymptomatic. However, when symptomatic, cervical dysplasia presents with postcoital bleeding rather than pelvic pain. (Choice C) Primary ovarian insufficiency typically occurs in patients with a history of autoimmune disease, previous chemoradiation, or Turner syndrome. Typical presentation is secondary amenorrhea and symptoms of menopause (eg, hot flashes, vaginal dryness). (Choice D) A tubo-ovarian abscess is a complication of pelvic inflammatory disease and may present with pelvic pain and an adnexal mass; additional findings required for diagnosis are fever and leukocytosis. This patient is at decreased risk due to condom use. (Choice E) Uterine sarcoma (eg, leiomyosarcoma) is a rare gynecologic malignancy associated with a history of pelvic radiation and tamoxifen use. Typical presentation is with postmenopausal or abnormal uterine bleeding and an irregularly shaped, rapidly enlarging uterus. Educational objective: Endometriosis may present with pelvic pain, dyschezia, rectovaginal nodularity, and an ovarian mass (endometrioma). Endometriosis causes pelvic adhesions and inflammation, leading to infertility and chronic pelvic pain. References: When love hurts. A systematic review on the effects of endometriosis surgical and pharmacological treatments on female sexual functioning. (http://www.ncbi.nlm.nih.gov/pubmed/27687240) Safety of medical treatments for endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/26576479) Endometriosis-associated infertility: aspects of pathophysiological mechanisms and treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/27998009)

A 22-Year-Old Woman Comes to the Office with Right Lower