Notes

Laparoscopy can be both diagnostic and therapeutic in this patient in whom you suspect endometriosis.
Interstitial cystitis (IC) is a chronic inflammatory condition of the bladder, which is clinically characterized by recurrent irritative voiding symptoms of urgency and frequency, in the absence of objective evidence of another disease that could cause the symptoms. Pelvic pain is reported by up to 70% of women with IC and, occasionally, it is the presenting symptom or chief complaint. Women may also experience dyspareunia. The specific etiology is unknown.
Diagnosis is based on the Rome II Criteria for IBS, which includes at least 12 weeks (need not be consecutive) in the preceding 12 months of abdominal discomfort or pain that has two of three features: 1) relief with defecation; 2) onset associated with a change in frequency of stool; or 3) onset associated with a change in stool form or appearance.
Danazol, a 17-alpha-ethinyl testosterone derivative, suppresses the mid-cycle surges of LH and FSH.
It is estimated that chronic pelvic pain is the principal preoperative indication for 10-12% of hysterectomies. Since the patient had a tubal ligation and does not desire any more children, the best option is removal of ovaries with or without a hysterectomy. Repeat laparoscopy with treatment of endometriosis and adhesions can be helpful; however, the patient will continue to be at increased risk of recurrent disease. An endometrial ablation or wedge resection of ovaries alone would not be very helpful in the setting of non-cyclical pain.
Given the patient’s age, nonspecific abdomino-pelvic symptoms, recent postmenopausal bleeding episode and family history of ovarian cancer, a transvaginal ultrasound is the next best step as it is more sensitive than CT for evaluation of the uterus and adnexa.
Ovarian remnant syndrome occurs following surgical removal of the ovaries, with subsequent development of cyclical pain due to ovarian tissue that was left behind inadvertently.
Pelvic congestion syndrome is a cause of chronic pelvic pain occurring in the setting of pelvic varicosities. The unique characteristics of the pelvic veins make them vulnerable to chronic dilatation with stasis leading to vascular congestion.
Nerve entrapment syndrome is a commonly misdiagnosed neuropathy that can complicate pelvic surgical procedures performed through a low transverse incision. The nerves at risk are the iliohypogastric nerve (T-12, L-1) and the ilioinguinal (T-12, L-1) nerve. The iliohypogastric nerve provides cutaneous sensation to the groin and the skin overlying the pubis. The ilioinguinal nerve follows a similar, although slightly lower, course as the iliohypogastric nerve where it provides cutaneous sensation to the groin, symphysis, labium and upper inner thigh. Damage to the obturator nerve, which can occur during lymph node dissection would result in the inability of the patient to adduct the thigh.
Fibroadenomas are common and are usually firm, painless and freely movable
Accurate prolactin levels are best obtained in the fasting state. If still elevated, then a TSH level and brain MRI would be indicated to rule out a pituitary tumor.
Fibrocystic breast changes are the most common type of benign breast conditions and occur most often during the reproductive years. Fibrocystic disease is often associated with cyclic mastalgia, possibly related to a pronounced hormonal response. Caffeine intake can increase the pain associated with fibrocystic breast changes, so recommending that she decrease her caffeine intake may be helpful.
Even though the mass decreased in size after aspiration, the bloody discharge obtained obligates an excisional biopsy be performed to rule out breast cancer. If clear discharge is obtained on aspiration and the mass resolves, reexamination in two months is appropriate to check that the cyst has not recurred.
Puerperal mastitis refers to mastitis occurring during pregnancy and lactation.
Most postpartum mastitis is caused by staphylococcus aureus, so a penicillin-type drug is the first line of treatment. Dicloxacillin/Keflex(Cefalexin) is used due to the large prevalence of penicillin resistant staphylococci. Erythromycin may be used in penicillin allergic patients.