A 32-year-old woman presents to her primary care provider with pelvic pain. She reports that for the last several years, she has had chronic pain that is worse just before her menstrual period. Over the past 2 months, she has also had worsening pain during intercourse. She denies dysuria, vaginal discharge, or vaginal pruritus. The patient has never been pregnant and previously used a copper intrauterine device (IUD) for contraception, but she had the IUD removed 1 year ago because it worsened her menorrhagia. She has now been using combined oral contraceptive pills (OCPs) for nearly 1 year. The patient reports improvement in her menorrhagia on the OCPs but denies any improvement in her pain. Her medical history is otherwise unremarkable. Her temperature is 98.0°F (36.7°C), blood pressure is 124/73 mmHg, pulse is 68/min, and respirations are 12/min. The patient has pain with lateral displacement of the cervix on pelvic exam. A pelvic ultrasound shows no abnormalities, and a urine pregnancy test is negative. Which of the following is most likely to confirm the diagnosis?
Hysteroscopy
Abdominal ultrasound
Hysterosalpingogram
Laparoscopy
Laparoscopy
This patient presents with chronic pelvic pain that is worse before her menstrual period, vaginal tenderness on physical exam, and lateral displacement of the cervix, which is consistent with a diagnosis of endometriosis. Since this patient has failed therapy with oral contraceptive pills (OCPs), she should undergo laparoscopy.

Endometriosis classically presents with chronic pelvic pain and the “3 D symptoms” of dysmenorrhea, dyspareunia, and dyschezia. Since laparoscopy with biopsy is required for definitive diagnosis, patients with suspected endometriosis may be empirically managed with OCPs and NSAIDs. Most patients achieve symptom control on this regimen. If patients fail empiric therapy, have contraindications to hormonal therapy, or have severe symptoms they should undergo laparoscopy for both definitive diagnosis and treatment of the disease.

Vercellini et al. review the evidence regarding the diagnosis and treatment of endometriosis. They discuss how the diagnosis of this disorder is carried out by direct visualization and histologic examination of lesions. They recommend medical treatment for symptomatic relief and surgical excision in refractory patients.

Incorrect Answers:
Answer A: Abdominal ultrasound is less accurate than a transvaginal ultrasound which has already been performed. Since there were no findings on transvaginal ultrasound, it is unlikely that abdominal ultrasound would reveal pathology. This modality would be effective for intra-abdominal disorders such as cholelithiasis or appendicitis (in pediatric and pregnant patients to avoid radiation exposure).

Answer B: Hysterosalpingogram is more useful in the workup of infertility, particularly for patients with a history of pelvic inflammatory disease. It is not routinely used to diagnose endometriosis. Patients with pelvic inflammatory disease present with fever, purulent discharge, and cervical motion tenderness. Treatment is with antibiotics.

Answer C: Hysteroscopy is used in the workup of abnormal uterine bleeding, fibroids, and endometrial thickening or polyps. Since endometriosis is defined as endometrial glands and stroma outside of the uterine cavity, a hysteroscopy is not particularly helpful in making the diagnosis. Treatment for polyps or fibroids is with surgical excision.

Answer E: Pelvic MRI can be used to better characterize an abnormality seen on pelvic ultrasound or CT or to diagnose adenomyosis. It can aid in making the diagnosis of endometriosis but is not the most accurate/confirmatory test. A laparoscopy would both be diagnostic and therapeutic for this disorder.

Bullet Summary:
Patients with suspected endometriosis may be managed empirically with oral contraceptive pills and NSAIDs, but laparoscopy with biopsy is necessary for definitive diagnosis and management.