Avoiding “shotgun” treatment: New thoughts on endometriosis- associated pelvic pain

40 OBG Management | May 2015 | Vol. 27 No. 5 obgmanagement.com CASE Resurgent, worsening dysmenorrhea A 32-year-old woman (G2P2) with a history of 2 spontaneous vaginal deliveries presents to your office after 10 months of severe, worsening dysmenorrhea. Shortly after she developed severe dysmenorrhea, she began to experience daily pain in her lower abdomen and pelvis. This pain occurred in the midline, bilateral lower quadrants, and rectum. She also developed deep dyspareunia. She has a history of dysmenorrhea from adolescence but has otherwise been healthy and pain-free until the past 10 months. She has tried oral contraceptives and nonsteroidal anti-inflammatory drugs, without success. She is happily married, and her medical history is unremarkable except for a bout of Lyme disease 6 months before the onset of pain, at which time she also developed symptoms of fatigue. A physical examination is remarkable for unilateral thickening and shortening of the left uterosacral ligament, dense scarring, and tenderness at the posterior fornix, with poor uterine mobility. Magnetic resonance imaging reveals findings consistent with the physical examination. What is causing her pain after such a long phase without it? And what treatments should you offer her?