Case Scenario

A 27-year-old woman presents for a new patient visit to discuss chronic, severe menstrual-related pain that began at menarche when she was 12 years of age, causing her to miss many days of school and work. Over the past few years, she has been examined by her primary care physician several times and consulted a gynecologist for the pain, which is associated with nausea, diarrhea, and abdominal bloating. Results of abdominal and pelvic examinations and laboratory testing, including a complete blood count, comprehensive metabolic profile, thyroid-stimulating hormone level, progesterone level, and tests for sexually transmitted infections, were normal. Dysmenorrhea was diagnosed, and the patient was treated with ibuprofen, naproxen, and several trials of oral contraceptives, with little or no relief. She is constantly tired and feels anxious and depressed. She is struggling at work, especially when she has her menstrual period, and recently broke up with her significant other because of her labile moods and emotional outbursts. She is tearful and appears to be desperate for help.

Clinical Commentary

EPIDEMIOLOGY

Endometriosis is an idiopathic inflammatory, estrogen-dependent condition caused by the presence of endometrial tissue outside of the uterus.¹ Endometriosis is characterized by painful and disabling menstrual symptoms. The most commonly reported symptoms are painful periods (62%), heavy/irregular bleeding (51%), and pelvic pain (37%).² Endometriosis affects approximately 10% of reproductive-aged women and others assigned female sex at birth.³ Endometriosis is more common in people with onset of menarche before 12 years of age, menstrual cycles of less than 24 days, lower parity, and lower lean body weight (i.e., the difference between total body weight and body fat weight).³ Up to 50% of people with concomitant infertility and chronic pelvic pain have endometriosis.³ Endometriosis has been called a “missed disease” due to its unclear etiology, lack of research, and inconsistency in diagnosis and management, leading to frequent diagnostic and therapeutic delays.⁴