More Than Bad Cramps

A 28-year-old woman comes to the gynecology clinic with severe, debilitating pelvic pain that began in her early 20s and has progressively worsened. She describes the pain as burning and stabbing, located in the lower abdomen and pelvis, and worsens 2-3 days before menstruation and peaks during menses. She also reports progressive deep dyspareunia, painful defecation, and cyclical rectal pressure. Over the past year, she’s developed urinary urgency and frequency around her period. She has missed several workdays due to the intensity of her symptoms and has begun to feel anxious about intercourse and menstruation. She and her partner have been trying to conceive for 18 months without success. On pelvic exam, the uterus is immobile and retroverted, with nodularity and exquisite tenderness along the uterosacral ligaments, and bilateral adnexal fullness. A transvaginal ultrasound reveals a 5 cm homogenous, hypoechoic ovarian cyst with a “ground-glass” appearance suggestive of an endometrioma.