From the Guidelines
The best next step in evaluation for this patient is a diagnostic imaging study, specifically an expanded protocol transvaginal ultrasound (TVUS) or an MRI protocol tailored for detection of deep endometriosis, as these imaging modalities have been shown to be highly sensitive in detecting endometriotic lesions. This 25-year-old woman presents with chronic pelvic and lower back pain that worsens before menstruation and improves toward the end of her cycle, which strongly suggests endometriosis. Despite treatment with NSAIDs and combined oral contraceptives for 9 months, she has experienced minimal improvement. The physical examination findings of tenderness in the posterior vaginal fornix, decreased uterine mobility, and thickening of the uterosacral ligaments further support this diagnosis. According to the American College of Radiology Appropriateness Criteria 1, imaging studies such as expanded protocol TVUS or MRI can help diagnose endometriosis and inform treatment planning. These imaging modalities can detect endometriotic lesions, particularly deep endometriosis, which may not be visible on routine transvaginal ultrasound.
Some key points to consider in the evaluation of this patient include:
- The use of expanded protocol TVUS, which involves a more detailed imaging protocol that includes anatomy and scanning maneuvers not part of the standard female pelvic US 1.
- The importance of MRI in detecting deep endometriosis, particularly with the use of moderate bladder distention and vaginal contrast to improve lesion conspicuity 1.
- The potential benefits of imaging studies in reducing morbidity and mortality, and reducing the need for repeat surgeries by reducing the number of incomplete surgeries 1.
Given the patient's persistent symptoms despite medical management and the classic clinical presentation suggesting endometriosis, a diagnostic imaging study such as expanded protocol TVUS or MRI is the best next step in evaluation, as it can provide valuable information for diagnosis and treatment planning, and may help avoid the need for more invasive procedures such as diagnostic laparoscopy.
From the Research
Evaluation of the Patient
The patient presents with pelvic and lower back pain that worsens before menstruation and improves toward the end of her cycle. She has been taking ibuprofen and combined oral contraceptives for 9 months with minimal improvement in pain. The examination reveals tenderness in the posterior vaginal fornix, decreased uterine mobility, and thickening of the uterosacral ligaments.
Possible Diagnosis
Based on the patient's symptoms and examination findings, endometriosis is a possible diagnosis.
- The patient's symptoms of pelvic pain and lower back pain that worsen before menstruation are consistent with endometriosis 2.
- The examination findings of tenderness in the posterior vaginal fornix, decreased uterine mobility, and thickening of the uterosacral ligaments are also consistent with endometriosis 2.
Next Steps in Evaluation
The next steps in evaluation of this patient could include:
- Laparoscopy, which is considered the gold standard for diagnosing endometriosis 2.
- Medical therapy, such as gonadotropin-releasing hormone (GnRH) agonists or antagonists, which can help alleviate symptoms of endometriosis 3, 4, 5.
- Combination of medical and surgical therapy, which may be beneficial in some cases 6.
Considerations for Treatment
When considering treatment options for this patient, it is essential to take into account the patient's symptoms, medical history, and preferences.
- The patient has already tried combined oral contraceptives with minimal improvement in pain, so alternative medical therapies may be considered 3, 4, 5.
- The patient's symptoms and examination findings suggest a possible diagnosis of endometriosis, which can be treated with a combination of medical and surgical therapies 2, 6.