A 28-year-old nulliparous woman comes to the clinic for an infertility evaluation. The patient has had unprotected intercourse with her husband for the past 12 months without conceiving and often experiences pain with deep vaginal penetration. Menarche was at age 11, and her menstrual period occurs every 26 days and lasts 5-7 days. Menstrual cycles are accompanied by moderate to severe lower abdominal pain. Pelvic examination shows a normal-sized, retroverted uterus. The posterior vaginal fornix is tender to palpation. Which of the following pathologic findings are most likely to be seen in this patient?
Endometriosis | |
Etiology |
|
Clinical features |
|
Diagnosis |
|
Complications |
|
This patient with dysmenorrhea and dyspareunia likely has endometriosis, the presence of ectopic endometrial glands and stroma in an extrauterine location (eg, peritoneal cavity). Risk factors include nulliparity, early menarche, and prolonged menses; in contrast, multiparity and late menarche lower the risk due to fewer menstrual cycles (ie, fewer opportunities for retrograde menstruation).
Like the uterine endometrium, ectopic endometrium undergoes periods of proliferation and breakdown concordant with the menstrual cycle. Although patients typically have regular menstrual cycles (eg, every 26 days, lasting 5 days), shedding from ectopic endometrial glands can form intraperitoneal blood collections, leading to dysmenorrhea. Over time, the blood undergoes hemolysis and induces pelvic inflammation followed by adhesion formation, which, in turn, distorts pelvic organ anatomy and function.
Pelvic inflammation and adhesions can cause infertility by interfering with ovulation, preventing fertilization by sperm, and inhibiting implantation. Tissue adhesions involving the uterosacral ligaments can also cause a fixed, retroverted uterus. In addition, nodular implants within the posterior cul-de-sac can lead to painful intercourse and tenderness with palpation of the posterior vaginal fornix.
(Choice B) Estrogen deficiency (eg, primary ovarian insufficiency, menopause) can cause glycogen deficiency in the vaginal epithelium and flattening of the vaginal rugae, which contribute to dyspareunia. However, this patient's regular menses indicate normal estrogen levels.
(Choice C) Endometrial hyperplasia increases the endometrial gland/stroma ratio because the primary risk factor, excess estrogen stimulation, preferentially stimulates glandular proliferation. In contrast to this patient with endometriosis, those with endometrial hyperplasia typically have irregular, anovulatory menses.
(Choice D) Multiple ovarian follicular cysts with cortical fibrosis occur in polycystic ovary syndrome (PCOS). Although PCOS can cause infertility due to anovulation, it is typically associated with obesity, hyperandrogenism (eg, hirsutism, acne), and oligomenorrhea. This patient's regular menses make this etiology unlikely.
(Choice E) Adenomyosis is the abnormal presence and proliferation of endometrial glands within the uterine myometrium. Although adenomyosis can cause dysmenorrhea, patients typically have heavy menses and a symmetrically enlarged uterus, which are not seen in this patient.
Educational objective:
Endometriosis is the presence of endometrial glands and stroma in an extrauterine location. Ectopic implants within the intraperitoneal cavity degenerate during menses and can cause abdominopelvic inflammation and the formation of tissue adhesions. Therefore, patients with endometriosis may have dysmenorrhea, dyspareunia, and infertility.