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A 36-year-old woman presented with a 2-month history of abdominal distention and pain. She reported having dysmenorrhea, dyspareunia, cyclical right shoulder pain (occurring only at the time of menstruation), and umbilical pain. The abdomen was tense and distended, with a purplish umbilical mass (Panel A). Vaginal examination revealed the presence of a rectovaginal nodule. Ultrasonography and magnetic resonance imaging showed ascites. At laparoscopy, 4.8 liters of hemorrhagic ascites was aspirated. Endometriotic nodules were observed on the ascending colon (Panel B), right hemidiaphragm, vesicouterine fold, and rectovaginal septum. All nodules (except those on the diaphragm) were excised. Pathological examination of the removed material confirmed a diagnosis of endometriosis. After surgery, the patient began taking 2.5 mg of norethindrone acetate per day, which she continues to take. At follow-up 1 year after surgery, she was free of pain and had no symptoms associated with endometriosis.
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