Endometriosis
Description:
Figure 2. Illustration of uterus with endometriosis (2018)
Endometriosis is the presence of functioning endometrial tissue or implants outside the uterus. Endometrial implants generally occur in the pelvic and abdominal cavities with the most common sites of implantation being the ovaries, uterine ligaments, recto-vaginal septum, and pelvic peritoneum. The ectopic endometrial tissue responds to hormone fluctuations during the menstrual cycle and bleeds, leading to inflammation, fibrosis, scarring, and pain. The most common symptoms are pelvic pain and infertility. Additional symptoms include dysmenorrhea, dysuria, dyschezia (pain on defecation), and dyspareunia (pain on intercourse). Constipation and abnormal vaginal bleeding may also be present (McCance & Huether, 2019, p. 777).
Rationale:
Our patient presents with several signs and symptoms for endometriosis including pelvic pain, infertility, irregular bleeding, irregular menstrual cycle, constipation, and pain during intercourse. She has a history of a non-cancerous pelvic mass, likely from the displaced endometrium, and an early menarche. Additionally, endometriosis is familial, and causes an increased risk for ovarian cancer (McCance & Huether, 2019, p. 776). We see her familial history may support a diagnosis of endometriosis; her sister is having infertility struggles as well and her grandmother passed from ovarian cancer. Definitive diagnosis for endometriosis involves a laparoscopy procedure to determine if ectopic endometrial tissue is present (McCance & Huether, 2019, p. 776).
Irritable Bowel Syndrome (IBS)
Description:
Figure 3. Illustration of intestines with IBS (2015)
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder that is characterized by lower abdominal pain, diarrhea-predominant, constipation-predominant or alternating diarrhea/constipation, gas, bloating and nausea. Patients may also experience fecal urgency and incomplete evacuation. Their symptoms usually go away after a bowel movement. The pathophysiology of IBS is complex and there are no specific structural or biochemical alterations that have been identified as a cause. A multi system interaction is considered to be the cause of widely varying symptom presentation. IBS affects approximately 7-20 percent of individuals throughout the world and is more common in women. There is no cure and treatment is individualized based on patient symptoms (McCance & Huether, 2019, p. 1340).
Rationale:
Our female patient presented with both abdominal pain and constipation, both signs that are indicative of IBS. However, the difficulty with pregnancy, the cessation of menses, and the dyspareunia point to something more serious than IBS and more match the symptoms of endometriosis. Diagnosis for IBS would involve the presence of abdominal pain at least 1 day per week for the last 3 months as well as at least two of the following: pain with defecation, a change in stool frequency, and difference in how the stool looks (McCance & Huether, 2019, p. 1340).
Pelvic Inflammatory Disease (PID)
Description:
Figure 4. Illustration of uterus with pelvic inflammatory disease (2017)
Pelvic Inflammatory Disease (PID) is an acute inflammatory response of the upper genital tract caused by an infection. In severe cases, it can involve the entire peritoneal cavity. The most common infections that cause PID are gonorrhea and chlamydia. Symptoms may vary, however the first sign on PID is usually a dull abdominal pain that may worsen with walking, intercourse or other movements. Irregular bleeding, dysuria (difficult or painful urination) and dyspareunia may also be present. Minimun criteria for diagnosis of PID includes cervical motion tenderness, uterine tenderness, or adnexal tenderness as well as accompanying fever, cervical or vaginal discharge, elevated C-reactive protein levels, and/or an elevated white blood cell count (McCance & Huether, 2019, p. 768).
Rationale:
While our patient did present with irregular bleeding, abdominal pain, and dyspareunia, she did not present with a fever or any symptoms of infection. Additionally, our patient is likely at a low risk for sexual transmitted infection (STI) with a recent negative STI test and her monogamous status, age, and absent history of infection. A definitive criteria for PID includes trans-vaginal ultrasound, MRI, doppler studies showing thickened and fluid filled tubes, laparoscopic visualization of PID-related abnormalities, or endometrial biopsy with evidence of endometritis (McCance & Huether, 2019, p. 768).
Ovarian Cysts
Description:
Figure 5. Illustration of uterus with follicular cysts (2017)
Ovarian cysts are fluid filled sacs or pockets that form on the outside or inside of the ovary. Ovarian cysts are most common during reproductive years as hormonal imbalances are most common around puberty and menopause, but can happen at any time in life. Benign ovarian cysts are quite common, and compromise 1/3rd of gynecologic hospital admissions. The most common are are follicular and corpus luteum cysts, but dermoid cysts should also be considered. Cysts are caused by variations of normal physiologic events, all of which include hormonal imbalances that fail to signal the normal physiology of the menstruation process or the uterine and/or ovary development. Although most patients are asymptomatic, some patients present with nonspecific symptoms. Symptoms can include: abdominal bloating, swollen and tender breasts, heavy menses, irregular vaginal bleeding, amenorrhea, delayed menstruation, abdominal or pelvic pain, pain during intercourse, or irregular bowel movements (McCance & Huether, 2019, p. 773).
Rationale:
While our patient did present with abdominal pain, irregular menses, and pain during intercourse, most cysts are asymptomatic. Therefore, possessing multiple symptoms points more strongly to endometriosis. In addition, ovarian cysts do not usually prevent pregnancy and are most common during puberty and menopause. However, to issue a definitive diagnosis due to the symptom similarity, ovarian cysts can and will need to be ruled out by by a pelvic exam or trans-vaginal ultrasound (McCance & Huether, 2019, p. 773).