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Images
in Women's Health
January 2003
Case A 24-year-old woman, G0, presents with pelvic pain and has a history of stage II/III endometriosis diagnosed by direct visualization on laparoscopy, but no biopsies were taken and no surgical treatment was provided. She has been treated with leuprolide (Lupron Depot) for 6 months and has had relief of pain for the most part. Around the third week after the Lupron Depot shots, she periodically notes pain. Her pain is better on Lupron Depot and she would like to continue it. In addition to the Lupron Depot, she does use ibuprofen, propoxyphene napsylate (Darvocet), and/or hydrocodone bitartrate and acetaminophen (Vicodan) to control the pain intermittently.
Her past medical history is significant for anorexia nervosa with intensive therapy for 1.5 years and she continues in supportive therapy although she has gained her weight back. The anorexia is under control. She also had severe dysplasia/carcinoma-in situ of the cervix and was treated with loop electrical excision at age 17, and follow-up Pap tests have been normal. She never had any radiation therapy or chemotherapy. She has asthma, which is controlled with albuterol and asthmacort on an as-needed basis. At age 9 she had a tonsillectomy.
Her height is 66 inches, weight 148 lbs, and her blood pressure is 110/80.
Her examination is notable for mild tenderness in the left lower quadrant. Otherwise, her abdomen is soft, nontender, nondistended, no rebound, and no hepatosplenomegaly. Her pelvic examination is essentially normal. Uterus is normal size, mobile and nontender. No adnexal masses are palpated. There is no recto-vaginal nodularity or uterosacral nodularity.
A bone densitometry test was ordered and the results of the lumbar spine and hip are presented here.
What are the diagnoses on these images?
What would you offer this patient?
This bone densitometry result is consistent with low mineral density in both the lumbar sacral region and the hip. This is of particular concern in a patient of this age. This is the time when she should be reaching her peak bone mass. No other bone metabolic disorders were identified in the evaluation. This low bone density is probably due to the combination of the hypoestrogenism associated with Lupron Depot and anorexia nervosa. Despite the patient’s statement that the anorexia lasted about 1.5 years, it probably was present with hypoestrogenism for a period before the diagnosis was made.
This patient has had significant relief of her pelvic pain symptoms on Lupron Depot. She was offered continuous birth control pills, the assumption being that the endometriosis should be well controlled after 6 months of Lupron Depot; starting continuous birth control pills (OCs) (without placebo pills) immediately thereafter would allow the endometrial lining to remain thin and the amenorrhea would persist. In addition, the pain from endometriosis would be controlled without further bone loss from hypoestrogenism. However, the patient was reluctant to stop the Lupron Depot, and OC add-back therapy was not initiated. She was counseled to add appropriate calcium supplements and vitamin D to her diet. The patient will be monitored with biochemical markers and a bone densitometry.
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