Endometriosis? Diverticulitis?


Q: Dear Dr.,
I have been experiencing bouts of intense abdominal pain with severe vomiting periodically for the last three years. The bouts last about three days. I have gone a few months to a year between incidents. In between I returned to feeling normal with the exception of low back pain that I am not sure is related at all. I had also been told I had ovarian cysts but that they were small and normal to see on ultrasound. I have always had my menstrual cycles but the times between have varied between 21-34 days and the length of the menstruation time varies. This is a change from four years ago when it was consistently a four day menstruation pattern and although the cycle length sometimes varied not to such a degree. I had my hormone levels checked and they remain unchanged from the first time I had them done 10 years ago and are within the normal parameters for premenopausal women.

With the last incident of abdominal pain my abdomen was distended and I was rolling around with pain unable to straighten or walk. I had been unable to keep even sips of water or ice chips down that day as well. When pressed on my abdomen the pain was worse to touch on my right side. Most tender just below ribs and in the low pelvic region of the same side. I was sent for an ultrasound which showed moderate amount of free fluid in my abdominal cavity and small ovarian cyst. At the hospital blood work showed very slightly elevated white blood cells and my bilirubin counts were elevated. All other liver functions were normal and I have a history since childhood of elevated bilirubin. I am not a heavy drinker, I consume about 3-4 glasses of wine or an occasional cocktail at most per week. There are many weeks I don't drink alcohol at all. My CA-125 level was also elevated a bit at 105. All other lab values were completely within normal ranges. The ultrasound reported my liver, spleen, pancreas, and kidneys all appeared normal. I had an x-ray that showed areas of colon that were distended and small pockets of air.

I saw several doctors who had different views. I was told that the ovarian cyst looked completely normal and too small to suspect causing the symptoms as did my ovaries and that it seemed to be a colon issue. Diverticulitis was discussed. The internist I saw though didn't agree and said elevated CA-125 without elevated other markers is not indicative of it being a colon issue to him although a colonoscopy to rule out problems was not a bad idea to him. Another doctor said that such a small cyst didn't seem likely to cause the ascitis or amount of pain. I had mammogram done and it was normal. I had an MRI that was to look at my pelvis and it showed small ovarian cysts that were possibly blood filled but only 3mm size. The MRI report summary was suspected, possible endometriosis. Otherwise no other abnormal findings or abnormalities were seen. The symptoms gradually resolved on their own after fluids and one day of medication called Buscopan for abdominal cramps. I also took a course of antibiotics but the prescribing doctor told me that it was more a precautionary measure as I had the slightly elevated white blood cell count. They didn't suspect peritonitis or other serious infection. An ultrasound a week later showed just small ovarian cyst again that appeared normal and a very small amount of free fluid in my abdomen, much less then before so resolving. The gynocologist I saw at that time said CA-125 can be elevated due to any pelvic inflammatory process and that my ovaries and uterus looked very normal and the cyst seen was quite small. They said a diagnostic laparoscopy could be done but that they didn't suspect ovarian cancer with the exam and other lab work at all. My recent Pap smear results were normal as well.

I have returned to normal activity and feeling well other then some back discomfort and small remaining tenderness in my right side. I am fairly active, I do a lot of horseback riding and like to run with my dog. I wish to remain active and I hate going to doctors. I am not sure what to think in all this or what I should do if anything as a next course of action. Does any of this make any sense to you and what would your recommendation be? Do you think endometriosis is the answer for the fluid and cramps in my abdomen? Even with such tiny cysts? Or does this seem unlikely? Should I have a laparoscopy or a colonoscopy? Or do I really need either? I am very much for avoiding unnecessarily medical treatments, I'm just not sure how I should take these symptoms or interpret them. The doctors I've spoken with so far also seem very ambivalent.

Thank you very much for your time and assistance.
Sincerely, Elizabeth Windholz


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