Question

A 42-year-old G0 woman with stage IV endometriosis presents with chronic pelvic pain. For the past three years, the patient has had worsening cyclic pelvic pain along with dyspareunia. Her pain has been unresponsive to continuous and cyclic contraceptive pills and depot medroxyprogesterone acetate injections. It has been slightly responsive to leuprolide acetate injections. She is currently taking ibuprofen and hydrocodone for pain relief. She does not desire fertility. Pelvic exam is notable for uterine and bilateral adnexal tenderness with uterosacral nodularity. Uterus is normal size and retroverted. A pelvic ultrasound is normal. The patient desires definitive treatment. What is the next best step in the management of this patient?

A. Laparoscopy with excision of endometriosis
B. Radical hysterectomy
C. Levonorgestrel IUD
D. Hysterectomy with bilateral salpingo-oophorectomy
E. Endometrial ablation

Answer 1

The best management step for a 42-year-old woman with stage IV endometriosis, who does not desire fertility and has not responded to conservative treatments, is a hysterectomy with bilateral salpingo-oophorectomy.

Step-by-step explanation:

The patient with stage IV endometriosis experiencing chronic pelvic pain, dyspareunia, and non-responsiveness to hormonal therapies is currently seeking a definitive treatment, and does not desire fertility. The next best step in the management of this patient, considering her age, symptoms, failed medical management, and lack of desire for fertility, would be a hysterectomy with bilateral salpingo-oophorectomy (presuming no contraindications to surgery). This procedure involves the removal of the uterus, cervix, and both ovaries and fallopian tubes, which would likely provide relief from her symptoms and prevent recurrence of endometriosis.

Laparoscopy with excision of endometriosis might be another option if fertility was a concern, or to confirm the diagnosis and extent of disease, but since definitive treatment is sought and fertility is not a concern, more aggressive surgical management is reasonable.