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Clinical Crossroads
December 22/29, 1999

A 36-Year-Old Woman With Endometriosis, Pelvic Pain, and Infertility

JAMA. 1999;282(24):2347-2354. doi:10.1001/jama.282.24.2347

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.