Case Description

A 53-year-old postmenopausal woman is referred to you for evaluation and management of a 3 cm ovarian mass. She had previously presented to the emergency department with hematuria and flank pain where she underwent a CT scan of the abdomen and pelvis to evaluate for nephrolithiasis. A small stone was visualized as well as a 3 cm cyst of the right ovary, suspected to be a mature cystic teratoma (dermoid cyst). She was managed expectantly and passed the stone without intervention.

Her obstetric history is significant for two uncomplicated vaginal deliveries. She has been menopausal for approximately two years. Prior to menopause she describes normal menses at regular intervals and has had minimal menopausal symptoms.

Her past medical history is complicated by hypothyroidism for which she takes levothyroxine. She has no past surgical history. She is married and sexually active with her husband and denies pain with intercourse. Normal age-related screening studies are up-to-date and normal as documented in the record.

Review of symptoms is negative for vaginal bleeding, change in bowel habits, pain with intercourse, or abdominal pain or bloating.

Physical Examination

General appearance Well-developed, well-nourished female in no apparent distress.

Temperature

98.6°F

Pulse

80 beats/min

Respiratory rate

16 breaths/min

Blood pressure

112/68 mm Hg

Height

5’6”

Weight

154 lb

BMI 24.9 kg/m²

Abdomen

Soft non-tender, no palpable mass, normal bowel sounds

Vulva/Vagina

Normal external genitalia with minimal atrophy, vaginal mucosa pale. No significant discharge

Cervix

Normal appearing

Adnexa Non-tender and non-palpable bilaterally

How Would You Evaluate and Manage This Patient?

Based on the patient’s normal history and physical exam, an ultrasound was obtained which showed a small complex ovarian mass containing elements consistent with a small mature cystic teratoma. The mass was unilocular with no internal vascularity on doppler (see Figure 72.1). CA-125 was obtained and noted to be 30 pg/ml, which is in the normal range. Based on the CT imaging, sonographic imaging, a normal CA-125, and the lack of associated symptoms, the patient was counseled for surveillance with a repeat ultrasound in three months.

Figure 72.1 Transvaginal ultrasound demonstrating a small 3 cm mature cystic teratoma of the right ovary.

Mature Cystic Teratoma in a Postmenopausal Female

Mature cystic teratomas are a common and benign germ cell tumor of the ovary. They are the most common type of germ cell tumor to arise from the ovary and although they are most common in premenopausal women, they are seen in postmenopausal women as well. The majority of patients are asymptomatic at the time of diagnosis and thus they are a common incidental finding on CT or ultrasound imaging studies.

These tumors arise from primordial germ cells of the ovarian tissue. They typically contain a combination of well-differentiated ectodermal, endodermal, and mesodermal tissue. Though diagnosis can only be made with certainty based on histologic review, the unique composition of these tumors leads to a characteristic appearance on ultrasound (Figures 72.1 and 72.2). This allows for a highly accurate imaging-based diagnosis with specificity reported to be 98 percent [1]. The most common ultrasound finding is an echogenic tubercle projecting into the cyst lumen. This is often referred to as a “Rokitansky nodule.” A hemorrhagic cyst or an endometrioma may also be considered in the sonographic differential. In cases where a confident diagnosis cannot be made with ultrasound, other imaging modalities can be considered. CT and MRI are highly sensitive in detecting fat, and thus diagnosis of a mature cystic teratoma with these modalities is generally straightforward [2, 3]. Ultrasound is used most often in surveillance of these tumors. If the initial diagnosis is made by CT or MRI, obtaining a baseline ultrasound can allow for more straightforward comparison with future imaging.

Figure 72.2 Transabdominal ultrasound demonstrating a large 11 cm mature cystic teratoma of the left ovary.

Complications from mature cystic teratomas are rare, though they can become quite large and lead to ovarian torsion and pain. Cyst rupture has been reported to occur and although rare, can lead to a chemical peritonitis either through an acute or chronic process [4]. Malignant transformation is rare but can occur and is most likely a squamous cell carcinoma arising from the ectoderm.

In a postmenopausal woman with a newly diagnosed ovarian cyst, a serum CA-125 aids in the assessment for a possible malignancy. This tumor marker is of most use in identifying women with a non-mucinous epithelial ovarian cancer. The sensitivity of CA-125 for predicting malignancy has been reported to be 35–91 percent and the specificity 67–90 percent. The wide variation in these values is due to the inclusion of both postmenopausal and premenopausal women in the studies. Because of the higher incidence of ovarian cancer in postmenopausal women, CA-125 is a more useful marker in this population [5, 6]. Case reports describing malignant transformation of a mature teratoma into a squamous cell carcinoma do describe elevations in carcinoembryonic antigen, but there are no studies to validate use of this tumor marker in the routine workup of a mature cystic teratoma [7]. For a postmenopausal patient with imaging consistent with a mature cystic teratoma and a normal CA-125, the clinician can be reasonably certain of the diagnosis and proceed with appropriate management. Based on current evidence, use of additional serum laboratory studies is of limited value.

The primary treatment of symptomatic or large mature cystic teratomas of the ovary is surgical excision. This can be accomplished either laparoscopically or through an open technique, though the majority of cases are amenable to a laparoscopic approach. Laparoscopy is associated with improved surgical outcomes, including less blood loss and a shorter hospital stay. The cyst is more likely to be ruptured with laparoscopy than with an open procedure and caution should be taken in these circumstances to thoroughly irrigate the abdomen and pelvis, but cases of chemical peritonitis in the event of cyst rupture are exceedingly rare [8]. For premenopausal women, cystectomy is typically preferred. In postmenopausal patients or patients who have completed childbearing, oophorectomy can be considered.

Conservative management of suspected mature cystic teratomas of the ovary is evidence based [9]. Appropriate candidates are patients who are asymptomatic, have small cysts, and have no imaging or laboratory findings to suggest a possible malignancy. There is no widely agreed-upon criteria for determining which size of cysts should be conservatively managed. Some guidelines suggest cysts less than 10 cm can be managed without surgery while other studies use criteria of 6 cm or less [1, 10]. As cyst size increases, patients are more likely to be symptomatic and will also assume more risk of complication such as ovarian torsion. If conservative management is chosen, serial imaging should be used to assess for stability. The ideal interval of repeat imaging is not known. One prospective study utilized ultrasound at three months after initial diagnosis and then every six months for the first two years. Ultrasound was continued annually if the cyst remained stable [10]. Some experts advocate for discontinuing imaging after 24 months for stable lesions in patients who remain asymptomatic [11].

Teaching Points

1. 
   

   1. Ultrasound is the preferred imaging modality for suspected mature cystic teratomas due to its low cost and lack of radiation exposure. CT and MRI also have high diagnostic accuracy.

   
   
2. 
   

   2. Asymptomatic, small mature cystic teratomas may be managed conservatively.

   
   
3. 
   

   3. For symptomatic or large mature cystic teratomas, surgical excision via laparoscopic cystectomy or oophorectomy is the preferred route.

History of Present Illness

A 60-year-old woman, gravida 2, para 2, is referred from her primary care physician (PCP) for an ovarian cyst found on imaging. The patient was initially seen by her PCP for left-sided abdominal pain. CT scan of the abdomen and pelvis obtained at initial evaluation revealed evidence of diverticulosis and a 4 cm simple-appearing right ovarian cyst. She presents for consultation due to concern for the ovarian cyst. Her pain has since completely resolved with dietary changes. She denies feeling pelvic fullness, early satiety, or bloating.

Her past medical history is significant for chronic hypertension, which is well controlled with metoprolol. She takes no other medications. Her prior surgical history includes a postpartum bilateral tubal ligation. Menstrual history includes menarche at age 13, regular cyclic menses, and menopause at age 53. Her most recent cervical cancer screening is current and showed normal cytology with negative high-risk HPV cotesting. She has no family history of ovarian, breast, or colon cancer.

Physical Examination

General appearance

Well-developed, overweight female in no acute distress

Temperature

37.0°C

Pulse

65 beats/min

Blood pressure

132/81 mm Hg

Respiratory rate

18 breaths/min

Oxygen saturation

98% on room air

BMI

25.6 kg/m²

Neck

No masses or lymphadenopathy

Axillae

No masses or lymphadenopathy

Chest

Clear to auscultation bilaterally

Abdomen

Soft, non-tender, non-distended, normal active bowel sounds, no palpable masses, no hepatosplenomegaly, no fluid wave

External genitalia

Unremarkable, no lymphadenopathy

Vulva/vagina

No lesions, scant discharge and loss of ruggae and pale appearing

Cervix

No lesions or cervical motion tenderness

Uterus

Six-week size, mobile, non-tender, no masses

Adnexa

Right ovary approximately 4 cm by 3 cm in size, mobile and non-tender. Left ovary not palpable.

How Would You Manage This Patient?

The source of the patient’s previous left-sided abdominal pain has been identified as diverticulosis and managed successfully by her primary care physician. As the patient is asymptomatic and the ovarian cyst is small and simple-appearing on CT, management should be guided by risk of malignancy. Further evaluation of the adnexal mass would include serum testing and a transvaginal ultrasound. The ovarian cyst was characterized on ultrasound as a simple, unilocular 4 cm right ovarian cyst. The left ovary was noted as a normal postmenopausal ovary, and no free fluid was noted in the pelvis (Figure 73.1). Her CA 125 level was reported as 12 U/mL. As these findings were consistent with a benign cyst, the recommendation was made to repeat the ultrasound imaging in three months. At follow-up ultrasound imaging, the cyst was noted to be slightly smaller at 3 cm but otherwise unchanged. The patient remained asymptomatic. Continued expectant management was recommended. Follow-up imaging revealed resolution of the cyst.

Figure 73.1 Ultrasound of 4 cm simple ovarian cyst.

Adnexal Masses in the Postmenopausal Patient

Approximately 15–20 percent of women will develop ovarian masses [1]. Most ovarian masses are benign, but the risk of malignancy increases sharply with age. There is a 3.5-fold increase of ovarian cancer in postmenopausal women compared with premenopausal women [2]. A strong family history of breast and/or ovarian cancer is also an important risk factor, especially if the history is suggestive of BRCA1 or BRCA2 mutations. The lifetime risk for ovarian cancer is estimated to be 1.3 percent in the general population, but increases to 39 percent for women with BRCA1 mutations and up to 17 percent for women with BRCA2 mutations [3]. Risk factors for malignancy also include early menarche, late menopause, endometriosis, nulliparity, and/or primary infertility.

Although postmenopausal patients with adnexal masses have a much higher risk of malignancy than premenopausal patients, the most common adnexal mass in a postmenopausal patient is a benign serous cystadenoma. Unilocular ovarian cysts, such as the one in this case, occur in approximately 5–14 percent of postmenopausal women and are almost universally benign [1].

A comprehensive history and physical examination is critical in the evaluation of a patient with an adnexal mass, including detailed gynecologic and family history as well as an in-depth review of systems. Ovarian cancer may be asymptomatic, but symptoms such as early satiety, urinary frequency or urgency, pelvic pain, generalized abdominal pain, or bloating may be present, particularly in later stages. For patients with adnexal masses, exams should include not only a thorough abdominal and pelvic exam but also palpation of lymph nodes and chest auscultation. A recto-vaginal exam may be necessary depending on the patient’s history, the characteristics of the mass, and other exam findings. Signs such as a fluid wave may be indicative of ascites, and any firm, nodular, or fixed mass warrants further investigation.

Transvaginal ultrasound is the preferred imaging modality for the initial evaluation of adnexal masses [4]. Though ultrasound has a low positive predictive value for malignancy, it can identify features of an adnexal mass which may be concerning for malignancy (Box 73.1). Several algorithms that use various clinical and ultrasound features to create risk-scoring systems have attempted to predict the probability of malignancy. Most of these systems accurately discern benign masses from malignancies; however, the results of a 2014 meta-analysis found that the International Ovarian Tumor Analysis (IOTA) Logistic Regression model 2 (with a risk cutoff of 10 percent) and the IOTA Simple Rules model both demonstrate high sensitivity and specificity and thus may be considered [5]. Though transvaginal ultrasound is the recommended imaging modality for the evaluation of adnexal masses, CT is more suitable for assessing the presence of other signs of possible malignancy (e.g., pelvic and/or periaortic lymph node enlargement, ascites, peritoneal or omental implants, hepatic masses) or for other potential sources of metastatic disease.

Serum marker testing may also be beneficial in evaluating the likelihood of malignancy. Cancer antigen 125 (CA 125) is a monoclonal antibody associated with epithelial ovarian cancers, and to date it is the most studied ovarian tumor marker. Unfortunately, its use as a marker for ovarian malignancy has limitations due to its poor sensitivity and specificity. CA 125 can be expressed by nonmalignant tissues and in patients with conditions such as pregnancy, pelvic inflammatory disease, endometriosis, systemic lupus erythematosus, adenomyosis, inflammatory bowel disease, and uterine fibroids. CA 125 is elevated in 50–80 percent of patients with epithelial ovarian cancer depending on disease stage [4], but is often normal in patients with other types of ovarian malignancies (i.e., germ cell, mucinous, or stromal cancers). Despite these limitations, CA 125 can be useful in the evaluation of adnexal masses, particularly for postmenopausal patients. Consultation with a gynecologic oncologist is appropriate for patients with a postmenopausal adnexal mass and a CA 125 level greater than 35 U/mL [4]. The American College of Obstetricians and Gynecologists previously recommended that premenopausal patients with an adnexal mass and CA 125 level greater than 200 U/mL be referred to a gynecologic oncologist; however, its most recent statement acknowledges that there is not an evidence-based cutoff and that the entire clinical picture should be considered when determining the need for referral [4].

Additional tumor marker testing may be indicated if there is suspicion of a non-epithelial ovarian malignancy. Serum biomarker panel testing may also be valuable in the workup of patients with adnexal masses. Panel testing is not recommended during the initial evaluation of patients with adnexal masses but can be used to identify patients who would benefit from consultation with a gynecologic oncologist. Serum biomarker panels such as the multivariate index assay have improved sensitivity and negative predictive value over CA 125 or clinical impression alone for the diagnosis of ovarian malignancy [4]. The Risk of Ovarian Malignancy Algorithm is more sensitive and specific in the detection of ovarian malignancy when compared to CA 125 alone [4]. Although the studies evaluating serum biomarker panel tests have been promising, their clinical utility is still in question.

After evaluation of a patient with an adnexal mass, the clinician must decide if the patient is a candidate for observation or if concerns for malignancy necessitate surgical intervention. In asymptomatic patients with benign-appearing cysts and with no suspicious laboratory findings, observation is generally recommended. Most of these masses are benign and many will resolve or regress spontaneously, even in women aged 50 and older [1, 6, 7]. Although estimates on the rates of resolution of these cysts vary, 69.4 percent of ovarian tumors measuring less than 10 cm spontaneously resolved in one study of 3,259 women aged 50 and older with unilocular cystic ovarian tumors [6]. Therefore, observation in these cases is reasonable; however, there currently are no accepted standards regarding the timing and duration of repeat imaging. In one study of 1,363 women aged 50 and older undergoing ultrasound observation of a complex adnexal mass, all but one of the masses later determined to be malignant demonstrated growth by seven months [7]. Although there is currently no clinical standard, some experts recommend limiting the observation of stable masses without solid components to one year [8].

For symptomatic patients and those with findings concerning for cancer, surgical management is indicated. If there is high clinical suspicion for malignancy, surgical intervention is best performed by a gynecologic oncologist with appropriate staging and debulking procedures. If the mass is believed to be benign, minimally invasive procedures are generally preferred; however, care should be taken to avoid intraoperative cyst rupture and spillage with subsequent iatrogenic upstaging of an undiagnosed malignancy. Concern exists for spillage with minimally invasive procedures; however, studies have found that the rates of spillage between patients undergoing laparoscopy versus laparotomy for clinically benign masses were equivalent [4]. Moreover, there were statistically significant improvements in pain control, length of hospital stay, and recuperation time with patients undergoing laparoscopic procedures [4]. Therefore, a minimally invasive approach is favored when appropriate.

Key Teaching Points

• 
  

  Most ovarian masses are benign, even in postmenopausal patients.

  
  
• 
  

  There are specific ultrasound findings that are more concerning for malignancy.

  
  
• 
  

  CA 125 levels have limitations, but may be useful in the evaluation of adnexal masses, especially for postmenopausal patients.

  
  
• 
  

  Many ovarian masses will spontaneously resolve and can be expectantly managed.

  
  
• 
  

  There is currently no clinical standard for the expectant management of adnexal masses; however, some have suggested limiting the observation of stable masses without solid components to one year.

  
  
• 
  

  If there is a high clinical suspicion of malignancy, surgical intervention is best performed by a gynecologic oncologist.

History of Present Illness

A 25-year-old nulligravid woman presents to the office for consultation due to an ovarian cyst. She reports menstrual cycles every 28 days, but started having intermenstrual bleeding three months ago. She describes the bleeding as light, mid-cycle, and lasting for two days. She sought the advice of her primary care physician, who ordered a pelvic ultrasound. The ultrasound identified a 2 cm simple ovarian cyst; therefore, she was referred for further management.

The patient is not taking hormonal contraceptives, as she is trying to conceive. She has no significant medical or surgical history. She has no family history of breast, ovarian, uterine, or colon cancer. She denies a history of sexually transmitted infections or pelvic inflammatory disease. She also denies a previous history of ovarian cysts, fibroids, or abnormal pap tests. Her periods are usually monthly, lasting five days with minimal discomfort. The patient’s last menstrual period was three weeks ago and was normal. Her pelvic ultrasound was performed ten days before her visit.

Physical Examination

Blood pressure

126/72

Heart rate

75

Temperature

98.6°F

Height 67 inches

Weight

145 lb

General appearance

Well-appearing woman who appears to be her stated age, in no apparent distress

Neck

Supple, no masses, thyroid palpable and normal size, no lymphadenopathy

Lungs

Clear to auscultation bilaterally

Heart

Regular rate and rhythm, without

murmurs, rubs, or gallops

Abdomen

Soft, non-tender, non-distended, without rebound or guarding

Vulva

Normal external female genitalia, no lesions. No groin lymphadenopathy

Vagina

Well rugated, no lesions, scant physiologic discharge

Cervix Normal-appearing, no lesions, no cervical motion tenderness

Uterus Small, anteverted, non-tender, mobile

Adnexae

Ovaries palpated bilaterally, non-tender, no masses identified

Gonorrhea and chlamydia

Negative

Cervical cytology

Negative one year ago

Pelvic ultrasound

The uterus measures 7.5 × 4.5 × 5 cm. The myometrium appears homogenous. The endometrial stripe measures 8 mm and is trilaminar. The right ovary measures 2.4 × 3.2 × 2.1 cm and has normal vascular flow. The left ovary measures 4.5 × 3.6 × 4.1 cm and has a 2 × 2.2 × 2.1 cm simple-appearing cyst within. The ovary has normal vascular flow. There is scant free fluid present in the cul de sac.

How Would You Manage This Patient?

This patient has a small, simple ovarian cyst that was incidentally identified and is asymptomatic. She has no evidence of cervicitis, and her cervical cancer screening is up-to-date and negative. Given her negative workup, with a normal-appearing uterus on ultrasound, the mid-cycle bleeding is most likely due to the physiologic drop in estradiol related to ovulation. Considering her menstrual pattern, the ultrasound was performed just prior to ovulation. Based on the timing and appearance on ultrasound, her ovarian cyst is most likely a follicular cyst.

In women with physiologic, asymptomatic ovarian changes, the most appropriate management is patient education and reassurance. This patient was counseled on the menstrual cycle and the expected appearance of the ovary in different phases of the cycle. She was reassured that her ovaries appear to be functioning properly and that no further imaging was necessary. In addition, because she is trying to conceive, she was educated about timed intercourse, given routine preconception counseling, and advised to begin taking prenatal vitamins.

Simple Ovarian Cysts in Premenopausal Women

When evaluating a patient with an ovarian cyst, special care should be taken to elicit a thorough gynecologic and family history. A review of systems, with particular focus on pain, bloating, early satiety, bowel symptoms, and pressure symptoms, can help to qualify the urgency of evaluation and workup, as well as assist in narrowing the differential diagnosis. A comprehensive physical exam including a thorough pelvic exam should be performed. The identification of lymphadenopathy, a fluid wave, or a firm or fixed adnexal mass should trigger a prompt evaluation for malignancy.

Pelvic ultrasound is the preferred modality to evaluate an incidentally found adnexal mass. Experienced sonographers should be able to qualify adnexal masses to help guide management. When possible, it is ideal to perform ultrasounds in reproductive-age women between day 5 and day 10 of the menstrual cycle in order to reduce the possibility of identifying a normal developing follicle [1]. If the imaging shows thin walls and the absence of complex findings, these cysts are almost always benign. An ultrasound that demonstrates a cyst with thick vascular septations, excrescences, solid components, or low-resistance Doppler flow is concerning for malignancy [2].

Benign pelvic masses can arise from gynecologic and non-gynecologic causes. From the gynecologic origins, masses can develop from the ovary, fallopian tube, and uterus. The ovary can produce many different varieties of benign cystic masses, including functional cysts, endometriomas, mature teratomas, and cystadenomas; however, the differential diagnosis of adnexal cysts would also include hydrosalpinges and paratubal cysts. It is estimated that about 7 percent of women worldwide will have an ovarian cyst at some time in their lives [3].

Most ovarian cysts in premenopausal women are incidentally discovered, are benign, and will resolve without intervention within six months. Ovarian cysts are typically divided into two categories: functional cysts and neoplastic cysts. A majority of ovarian cysts are functional, with follicular cysts and corpus luteal cysts being most common. Follicular cysts occur when a developing follicle does not rupture and continues to grow. They are typically unilocular and have a thin, smooth wall. Most are asymptomatic unless they rupture or undergo torsion. Corpus luteal cysts, which occur after a developing follicle ruptures in ovulation, can appear simple or complex on ultrasound. Internal echoes and thick walls can be present. Though they can grow to be quite large (up to 8 cm), corpus luteal cysts almost always resolve without intervention.

Cystadenomas are neoplastic cysts that can have serous or mucinous cells lining them, and these cells determine the contents of the cyst. The appearance on ultrasound varies, as they can be simple or have complex features with multilocular characteristics. Serous cystadenomas are more common than mucinous, and are more frequently bilateral. Differentiating serous from mucinous cystadenomas on imaging can be challenging; however, mucinous cystadenomas can grow to be very large and are more commonly multiloculated. Symptoms of benign neoplastic ovarian cysts may include pain and bloating, but these generally only present when a cyst grows quickly, becomes very large, or undergoes torsion. Cystadenomas are more likely to be persistent than functional cysts.

The management of the simple ovarian cyst depends on its size and whether or not the cyst is growing or is symptomatic. Simple cysts that are 3 cm or less generally represent follicular or other physiologic cysts, which are a normal finding and do not require follow-up or intervention. Similarly, cysts that are 5 cm or less do not require any additional treatment unless they are symptomatic. Annual pelvic examination is recommended, and repeat ultrasonography can be considered if any new symptoms or findings develop.

Simple cysts that are greater than 5 cm but less than 10 cm can be conservatively managed and monitored with serial ultrasonography, as the risk of malignancy in these cases is extraordinarily low. It is reasonable to initially perform repeat imaging in 6–12 weeks, with subsequent management dependent on whether the cyst resolves or persists. In cases where repeat ultrasonography documents resolution, no further follow-up is warranted. When repeat ultrasonography demonstrates persistence, serial ultrasounds should be performed every 6 to 12 months to ensure that the cyst is not enlarging or developing characteristics that may be concerning for malignancy. In cases where the cyst is larger than 10 cm, it is generally recommended to treat the patient surgically with cystectomy or oophorectomy. Nonetheless, simple cysts of this size have been noted to spontaneously resolve when managed with serial ultrasonography [4]. In cases in which an adnexal mass is going to be conservatively managed with observation, it is critical to educate the patient on signs and symptoms of adnexal torsion. The threshold for surgery should always be lowered when the cyst is associated with pain or other symptoms concerning for torsion.

Key Points

• 
  

  Pelvic ultrasound is the preferred modality to evaluate an adnexal mass, performed between day 5 and day 10 of the menstrual cycle.

  
  
• 
  

  Findings that indicate benign pathology include a unilocular cyst with thin walls.

  
  
• 
  

  Most ovarian cysts in premenopausal women are benign and will resolve without intervention within six months.

  
  
• 
  

  Simple cysts that are 3 cm or less are a normal finding and do not require follow-up or intervention.

  
  
• 
  

  Simple cysts up to 10 cm can be conservatively managed and monitored with ultrasound.

  
  
• 
  

  Indications for surgical management include >10 cm in diameter, complex findings on pelvic ultrasonography, and pelvic pain.

History of Present Illness

A 25-year-old, gravida 0, para 0, female presents to the office with gradually worsening painful menses and lower abdominal pain, predominantly on the right side. She describes her pain as aching in nature and worse during menstrual periods and sexual intercourse. She rates the pain as 7/10 at its worst. She states the pain used to be relieved by ibuprofen, but that is no longer the case. She denies frequency, burning, or other urinary complaints. She has normal bowel movements. She denies fever, chills, or fatigue.

The patient gives history of endometriosis diagnosed a few years ago during a diagnostic laparoscopy for pelvic pain, with temporary postoperative improvement reported after excision of the endometriosis implants. She does not have history of other medical problems or surgeries. She drinks alcohol socially, but denies smoking or illicit drug use. She has no known drug allergies. She has been married for the last three years and is not using condoms or any other form of contraceptives. Although they are not actively trying, she and her husband are open to the possibility of pregnancy.