Author Affiliation: Dr Adamson is the Director, Fertility Physicians of Northern California, Palo Alto and San Jose; Clinical Professor, Department of Gynecology and Obstetrics, Stanford University School of Medicine, Stanford, Calif; and Associate Clinical Professor, University of California San Francisco School of Medicine.
Clinical Crossroads at Beth Israel Deaconess Medical
Center is produced and edited by Thomas L. Delbanco, MD, Jennifer Daley,
MD, and Richard A. Parker, MD; Erin E. Hartman, MS, is managing editor. Clinical
Crossroads section editor: Margaret A. Winker, MD, Deputy Editor, JAMA.
DR DALEY: Ms B is a 36-year-old married medical
writer with pelvic pain, endometriosis, and infertility. She lives near Boston
with her husband and 1-year-old adopted daughter. She has managed care insurance.
Ms B experienced menarche at age 12 years. She reports moderate-to-severe
dysmenorrhea for many years, intermittent abdominal cramping, diarrhea, "gas,"
and occasional urinary urgency and frequency. In 1994, she attempted pregnancy.
Several months later, she was hospitalized with severe pelvic pain and a large
ovarian mass. Laparoscopic surgery revealed a large (8-10 cm) ruptured hemorrhagic
ovarian mass consistent with an endometrioma. The cyst was removed laparoscopically,
and Ms B began treatment with leuprolide acetate (Lupron Depot). She experienced
adverse effects including hot flashes and fatigue. During leuprolide therapy,
the endometrioma recurred, and she underwent a second laparoscopic endometriomectomy.
Ms B sought a second opinion and had a hysterosalpingogram that demonstrated
normal uterus, patent fallopian tubes, and scarred fimbria. A laparotomy showed
"severe endometriosis" with extensive pelvic scarring and adhesions. Ms B
declined another course of leuprolide therapy because of previous adverse
effects. She began acupuncture and herbal treatments.
Adamson GD. A 36-Year-Old Woman With Endometriosis, Pelvic Pain, and Infertility. JAMA. 1999;282(24):2347-2354. doi:10.1001/jama.282.24.2347