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A 34-year-old woman comes to the clinic because of left lower quadrant pain for the last 4 months. The pain is intermittent and seems to worsen during her periods. She has no significant past medical history and does not take any medications. She is sexually active with 1 partner and they use condoms for birth control. She has never been pregnant and has regular menstrual periods. Her last menstrual period was 17 days ago. Physical examination and vital signs are normal. Pelvic examination reveals mild tenderness in the mid and left side of the pelvis. There is no vaginal discharge or bleeding and the cervical os is closed. The most appropriate next step is to
A. order a CT scan of the pelvis
B. order ultrasonography of the pelvis
C. prescribe nonsteroidal antiinflammatory medications for menstrual cramps
D. prescribe oral contraceptives
E. schedule a diagnostic laparoscopy
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Explanation: The correct answer is B. The most likely cause of this patient's left sided pelvic pain is ovarian cysts. A follicular cyst occurs when the normal follicle does not shrink after the release of the egg. Follicular cysts are soft, have thin membrane walls, and contain clear fluid. They can rupture, causing sudden, severe pain that gradually goes away over several days. Usually, however, they spontaneously disappear over the course of 1 or more menstrual cycles. They can cause changes in periods and pelvic pain. Depending on the size of the cyst, it can just be observed for spontaneous resolution or treated with oral contraceptive pills. The best way to confirm the diagnosis of ovarian cysts is by ultrasonography of the pelvis.A CT of the pelvis (choice A) is not the best way to image the ovaries or to confirm the diagnosis of ovarian cysts. A CT does not provide the resolution that ultrasonography does to evaluate the cyst in fine detail in order to ensure that it is a simple cyst as opposed to a more worrisome complex cyst.Prescribing nonsteroidal antiinflammatory medications for menstrual cramps (choice C) is not appropriate in the management of this patient. She has had symptoms of intermittent pelvic pain for the last 4 months which makes menstrual cramps as the etiology of pain, less likely. It is important to further evaluate the pelvis for a cause of her symptoms and confirm the diagnosis of ovarian cysts. It is also important to rule out neoplastic causes of pain such as a cystadenoma or cystadenocarcinoma.Prescribing oral contraceptive pills (choice D) is a reasonable option once the diagnosis of an ovarian cyst is made. However, it is important to make the diagnosis first with ultrasonography of the pelvis. If the cyst appears simple on ultrasonography and is 4 cm or less in size, it can be followed with serial ultrasonography for resolution. For simple uncomplicated ovarian cysts in the premenopausal period, treatment with the administration of high-dose monophasic oral contraceptive pills (>35 mcg estradiol) is recommended after consultation with a gynecologist to normalize cycles and to facilitate reduction in cyst size.Diagnostic laparoscopy (choice E) allows direct visualization of the intraperitoneal contents including the ovaries which can add diagnostic yield. Surgical intervention and/or excision of relevant pathology may be accomplished by this method. This procedure is not the next appropriate step in the management of this patient. Ultrasonography of the pelvis usually provides sufficient information to make the diagnosis of simple uncomplicated ovarian cysts, without the need for direct visualization of the pelvic organs.
