247

HPI

94

CHAPTER 94
Lisbeth Anderson is a 30-year-old woman who was diagnosed with
endometriosis 3 months ago based on a history of dysmenorrhea,
intermittent pain with defecation, and past history of dyspareunia.
ENDOMETRIOSIS She presents to the nurse practitioner today for evaluation and
management of continued endometriosis-related pain despite treat-
Persistent Pelvic Pain . . . . . . . . . . . . . . . . . . . . Level II ment with naproxen.
Connie Kraus, PharmD, BCPS
PMH
s/p deep vein thrombosis 4 years ago after a flight to Southeast Asia;

LEARNING OBJECTIVES
After completing this case study, the reader should be able to:
Identify the signs and symptoms associated with endometrio-
sis.
Compare and contrast the benefits and risks associated with
various hormonal medications used for treatment of endo-
metriosis-associated pelvic pain.
Determine a treatment approach for this case taking into
account other health issues and potential health benefits.
Discuss possible side effects associated with treatment for
endometriosis.
PATIENT PRESENTATION
Endometriosis
treated for 6 months with warfarin; no recurrence
G1P1A0; one healthy male child aged 2 years
FH
Mother (aged 57 years) has a history of endometriosis, no other
health conditions; father (aged 58 years) has hypertension and
elevated cholesterol; one female sibling (aged 25 years) is healthy.
SH
Patient is a freelance photographer. She has one child. She is single;
not currently sexually active. She does not smoke and consumes no
more than two alcohol-containing beverages per week. She exercises
30 minutes most days of the week.
Meds
Naproxen 250 mg three times daily with food at first sign of menses
for 5–7 days was begun at previous visit.
Multivitamin one daily.

Chief Complaint All

“Although the pain associated with my menstrual period is better, NKDA
the naproxen upsets my stomach, and I am still having pain in my
lower abdomen at other times during the month.” ROS
(+) For moderate pain in pelvic region, (−) for constipation, men-
strual periods occur at regular intervals of 29 days

Physical Examination
Gen
WDWN female in NAD

VS
BP 115/70, P 65, RR 15, T 37°C; Wt 72 kg, Ht 5′11″; patient has
maintained same weight pre-pregnancy and postpregnancy

Skin
No lesions

HEENT
WNL

Neck/Lymph Nodes
Supple, no bruits, no adenopathy, no thyromegaly

Lungs/Thorax
CTA bilaterally

Breasts
Supple; no masses

CV
RRR, normal S and S
1 2
248
Abd Outcome Evaluation
Soft; patient states at baseline she experiences pain that averages a
SECTION 9

5. What clinical and laboratory parameters are necessary to evalu-

“4” on a 0–10 pain scale (with 10 being the worst possible pain), (+) ate the therapy for achievement of the desired therapeutic out-
BS; no masses noted come and to detect or prevent adverse effects?

Genit/Rect
Patient Education
Pelvic exam: (+) adnexal pain elicited and rated at “6” on a 10-point
6. What information should be provided to the patient to enhance
scale, no masses
adherence to the medication, ensure successful therapy, and
minimize adverse effects?
MS/Ext
Women’s Health (Gynecologic Disorders)

Pulses intact
CLINICAL COURSE
Neuro The patient returns to her nurse practitioner 6 months after start-
Normal sensory and motor levels ing medroxyprogesterone acetate 150 mg intramuscular injections
every 3 months. She reports that her pelvic pain is better controlled
Labs with an overall average rating pain of “1” on the 10-point scale. She
states that she had intermittent spotting initially, but now has no
Na 135 mEq/L Fasting lipid profile menstrual periods.
K 3.8 mEq/L T. chol 140 mg/dL
Cl 104 mEq/L LDL 55 mg/dL
CO2 25 mEq/L HDL 65 mg/dL Follow-Up Questions
BUN 10 mg/dL Trig 100 mg/dL 1. What is the optimal length of time for a patient to continue
SCr 0.6 mg/dL
on medroxyprogesterone acetate injections for treatment of
Random Glu 89 mg/dL
endometriosis-related chronic pelvic pain?
Other 2. Are there other options that this patient could select to achieve
PAP smear: Normal similar results with the same or better side-effect profile?
Chlamydia/gonorrhea: Negative 3. Would your recommendation change if this patient had risk fac-
Urine pregnancy test: Negative tors for osteopenia or future osteoporosis?
4. Would your recommendation change if this patient had indi-
Assessment cated an interest in having another child in the next 1–2 years?
A 30-year-old woman with recent diagnosis of endometriosis
with chronic pelvic pain; partial relief from dysmenorrhea with
naproxen. Because of naproxen-related side effects and pain at
SELF-STUDY ASSIGNMENTS
other times besides during menses, would like to consider hormonal 1. Research complementary therapies that have been studied for
treatment options. the relief of endometriosis, and compare the evidence for their
efficacy with standard treatments.
2. Review the contraindications of the various contraceptive agents
used for treatment of endometriosis.
QUESTIONS
Problem Identification CLINICAL PEARL
1.a. What are the patient’s current medication-related problems?
1.b. What information indicates the severity of this patient’s Pharmacologic treatment of endometriosis may be useful for
problems? decreasing pain. Pharmacotherapeutic agents that mimic preg-
nancy or menopause are the cornerstone of treatment. All of these
agents have similar efficacy in treating pain, but have different
Desired Outcome side-effect profiles. Treatment with hormonal therapy does not
2. What are the goals of therapy for this patient’s endometriosis improve fertility, which can also be a potential consequence of
pain? the disease.

Therapeutic Alternatives
3.a. What nondrug therapies might be useful for this patient?
REFERENCES
3.b. What hormonal options are available for the treatment of
endometriosis?
3.c. What are the potential risks and benefits of the various treat-
ment options for this patient?
3.d. Are there any treatments contraindicated in this patient?
Optimal Plan
4. What drug, dosage form, dose, schedule, and duration are best
for this patient?
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ment for endometriosis: back to the roots? Hum Reprod Update
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2. Flower A, Liu JP, Chen S, Lewith G, Little P. Chinese herbal medicine
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analogue for the treatment of chronic pelvic pain in women with endo- metriosis. Hum Reprod 2005;7:1993–1998.
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11. Department of Reproductive Health, World Health Organization.
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ning/9789241563888/en/index.html. Accessed May 9, 2010.