A 27-year-old nulliparous woman comes to the office due to left pelvic pain over the past 8 months. She has constant pelvic pressure exacerbated by exercise and sexual activity. The patient stopped taking combined oral contraceptives 2 years ago with the intention of having children but has not yet conceived. Her last menstrual period was 2 weeks ago. The patient's menstrual cycles are regular, occurring every 27 days with 4 days of bleeding. She was treated for trichomoniasis at age 20. Temperature is 37.2 C (99 F) and blood pressure is 120/72 mm Hg. Pelvic examination shows a normal-sized uterus with no abnormal cervical discharge. Bimanual examination reveals left adnexal tenderness. A unilocular mass with homogeneous, low-level echoes on the left ovary is seen on ultrasound. Which of the following is the most likely diagnosis in this patient?

Question

A 27-year-old nulliparous woman comes to the office due to left pelvic pain over the past 8 months.  She has constant pelvic pressure exacerbated by exercise and sexual activity.  The patient stopped taking combined oral contraceptives 2 years ago with the intention of having children but has not yet conceived.  Her last menstrual period was 2 weeks ago.  The patient's menstrual cycles are regular, occurring every 27 days with 4 days of bleeding.  She was treated for trichomoniasis at age 20.  Temperature is 37.2 C (99 F) and blood pressure is 120/72 mm Hg.  Pelvic examination shows a normal-sized uterus with no abnormal cervical discharge.  Bimanual examination reveals left adnexal tenderness.  A unilocular mass with homogeneous, low-level echoes on the left ovary is seen on ultrasound.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d989_dbb7_bc81_5b600ace721c_MD0003_00 This patient with chronic pelvic pain and an adnexal mass (ie, endometrioma) has endometriosis, or ectopic endometrial implants within the abdominopelvic cavity. Endometriosis likely occurs from a combination of cellular metaplasia and retrograde menstruation; the ectopic implants proliferate and shed during menses, causing intraabdominal inflammation, fibrosis, and pelvic pain. Endometriosis Pain symptoms vary depending on implant location. Patients with uterine or pelvic sidewall implants may have worsening pain with exercise or intercourse (ie, dyspareunia), as well as adhesion formation that can cause tubal infertility. Implants on the ovary can cause endometriomas, called chocolate cysts because of their thick, brown fluid from accumulated old blood. Endometriomas typically appear as a unilocular adnexal mass with homogeneous, low level echoes (ie, blood). Patients with symptomatic endometriomas require surgical resection (eg, cystectomy) to improve pain symptoms, improve fertility, and decrease the risk of ovarian torsion. chocolate cysts (Choice B) Epithelial ovarian carcinoma can present with an ovarian mass and pelvic pain, but ultrasound typically reveals a septate mass with solid and cystic components. (Choice C) Mature teratomas (ie, dermoid cysts) may cause pelvic pain or pressure, but they do not typically impair fertility. In addition, mature teratomas typically have calcifications and hyperechoic nodules on ultrasound. (Choice D) Pedunculated leiomyomas (ie, fibroids) can cause pelvic pressure due to mass effect; however, they arise from the uterus, not the ovaries. leiomyomas (Choice E) Pelvic congestion syndrome can cause pelvic pain associated with intercourse due to pelvic vein dilation. However, it occurs primarily in fertile women during or after pregnancy, and patients have visible venous dilation, rather than a unilocular, hypoechoic mass, on ultrasound. (Choice F) Tuboovarian abscess is a complication of pelvic inflammatory disease and may present with pelvic pain and an ovarian mass. It typically appears on ultrasound as a complex, multicystic adnexal mass with enhancing rims. Educational objective: Endometriosis is a common cause of pelvic pain, dyspareunia, and infertility due to ectopic implants of endometrial tissue in the abdominopelvic cavity. Implants on the ovary may form an endometrioma, which has the appearance of a unilocular, hypoechoic adnexal mass on ultrasound. References: Endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/20573761) Clinical practice. Endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/20573927) Laparoscopic surgery for endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/24696265)

A 27-Year-Old Nulliparous Woman Comes to the Office Due to Left