During a recent visit to an infertility specialist, a 35-year-old woman reports an inability to get pregnant over the past 2 years. During this time she also reports having irregular menses, menorrhagia, occasional suprapubic pain and dysuria, and occasional dyspareunia and painful defecation. A diagnostic laparoscopy reveals thickened adnexa, abdominal adhesions, two hemorrhagic cysts on the right ovary, and one ruptured hemorrhagic cyst on the left ovary. Microscopically, fibrotic patches of tissue found on the rectum and urinary tract reveal hemosiderin-laden glandular and stromal tissue. These collective findings most likely suggest a diagnosis of which of the following?
(B) luteal phase dysfunction
© ovarian carcinoma
(D) pelvic inflammatory disease
(E) polycystic ovary disease
(A) Endometriosis is the presence of endometrial tissue in a site other than the lining of the endometrial cavity. It most commonly occurs in the ovaries, wall of a fallopian tube, parametrial soft tissue, and serosa of the intestine but can also occur at many other locations. This condition may be asymptomatic but is an important cause of infertility, dysmenorrhea, and pelvic pain. Repeated episodes of hemorrhage result in fibrosis, which can lead to peritoneal adhesions or intestinal obstruction. Involvement of the fallopian tubes can block the lumen and lead to infertility and an increased risk of ectopic pregnancy. Luteal phase dysfunction (choice B) is also a cause of infertility. Even though ovulation may occur, insufficient progesterone is produced to prepare the endometrial lining for implantation. This is not associated with the other findings of the case described. Ovarian carcinoma (choice C) may be divided into three main types: primary epithelial tumors, germ cell tumors, and sex cord–stromal tumors. Most of these tumors remain clinically silent until quite advanced; although the prognosis varies depending on the type and stage of the tumor, it is generally not good. The presentation of the case does not match that of ovarian carcinoma. Pelvic inflammatory disease (choice D) is a common disorder in women in which there is infection of the fallopian tubes and ovaries as well as surrounding tissues. The most common causative agent is Neisseria gonorrhoeae, but several other organisms, including Chlamydia, have been implicated. Pelvic inflammatory disease is a cause of dyspareunia and sterility (as well as many other conditions), but the case does not indicate an infectious process and the hemorrhagic cysts are classic for endometriosis. Polycystic ovary disease (choice E) is characterized by bilaterally enlarged ovaries, numerous cystic follicles, and absence of corpora lutea (indicating failure of ovulation). In the presence of amenorrhea, this is referred to as the Stein–Leventhal syndrome. These patients have persistent anovulation, obesity, and hirsutism. This is one of the more common causes of infertility, but the other aspects of the case are not explained by polycystic ovary disease.