1 . Case Scenario 2
Table 1
Definition and how does this test work
What medical conditions or diagnoses are best suited for this test
Any special considerations or instructions prior to or during the test
Pelvic Ultrasound- Abdominal Ultrasound
Non-invasive imaging that allows visualization of organs & structures within the abdomen
Abnormalities of pelvic organs such as uterine fibroids, ovarian cysts, tumors
Best performed when the bladder is full
Pelvic Ultrasound- Transvaginal Ultrasound
Imaging where the probe is inserted into the vagina, which allows visualization of pelvic organs. Offers a more detailed visualization of the uterus & ovaries
Abnormal uterine bleeding, pelvic pain, ovarian cysts or tumors
Bladder needs to be empty prior to procedure
Saline infusion Sonohysterography
Saline is instilled into uterine cavity during a transvaginal ultrasound. This allows visualization of the endometrium
Uterine polyps, submucosal fibroids, intrauterine adhesions
Typically done during the proliferative phase of menstrual cycle (after menstruation, but before ovulation)
Hysteroscopy
A hysteroscope is inserted through vagina & cervix to examine the inside of the uterus
Uterine polyps, fibroids, intrauterine adhesions, uterine septum, abnormal uterine bleeding, repeated pregnancy loss
Typically done under anesthesia
HSG- hysterosalpingogram
Contrast dye is injection into the cervix to evaluate the structure of uterus & fallopian tubes via X-ray
Checking fallopian tubes for blockages & evaluating uterine cavity for abnormalities affecting fertility
Typically done in follicular phase of menstrual cycle when the pt is not pregnant & does not have an active pelvic infection
Laparoscopy
Minimally invasive surgical procedure with the aid of a laparoscope to visualize pelvic & abdominal organs
Endometriosis, pelvic adhesions, ovarian cysts, ectopic pregnancy, tubal blockages
Done under anesthesia
Endometrial Biopsy (EMB)
A procedure to obtain a sample of endometrial tissue
Evaluation of abnormal uterine bleeding, diagnosis of endometrial hyperplasia, cancer, & assessment of hormone therapy effects
Typically done in outpatient setting. May cause spotting and mild discomfort
Colposcopy
A colposcope is used to examine the cervix for abnormalities
Evaluation of abnormal Pap results, identification of cervical dysplasia or cancer
Avoid sexual intercourse, tampons, vaginal medication, or douching for 24 hours before the procedure
Endocervical Curettage (ECC)
Procedure where tissue samples are collected from endocervical canal
Evaluation of abnormal cervical cells, identification of cervical dysplasia or cancer
Often times done at the same time as a colposcopy
Dilation and curettage (D&C)
Surgical procedure to remove tissue from the uterus such as abnormal uterine bleeding or incomplete miscarriage
Abnormal uterine bleeding, uterine polyps, endometrial hyperplasia
Done under anesthesia
Donna is 35-year-old African American female who comes to the clinic complaining of pelvic pain that started as intermittent, but now is almost constant. She also complains of irregular vaginal bleeding/spotting that has occurred in between her monthly menses for the last six months. She has no family history of breast or ovarian cancer. Her vital signs (VS) and BMI are all within normal limits (WNL), but upon physical examination, you palpate a firm, raised area on her uterus. You note no cervical motion tenderness (CMT), no adnexal tenderness (AT), and no other abnormalities. She is G2 P2 with both normal spontaneous vaginal deliveries (NSVD) 10 and 8 years ago.
SOAP Note
Demographic Data
35-year-old female
Subjective
Chief Complaint (CC): Ive been having pain and bleeding in between my periods.
History of Present Illness (HPI) in paragraph form: A 41-year-old female presents to the clinic with a complaint of pelvic pain that started as intermittent, but now is almost constant. She cannot pinpoint the exact location of the pelvic pain, but she seems to feel it more on the left side. She described the pain as a pressure-like pain and rates it 7/10. In addition, the also complains of irregular vaginal bleeding/spotting that has occurred in between her monthly menses for the last six months. Aside from vaginal bleeding in between her menses, she denies recent changes in her menstrual cycle. She has always been fairly regular, with a 28-day cycle without heavy bleeding. She is currently sexually active with her husband of 10 years and has never been diagnosed with STIs in the past. She denies pain with intercourse or postcoital bleeding. She denies any associated symptoms of chills, fever, or recent weight changes. She does not have any family history of breast or ovarian cancer that she is aware of. She has tried taking OTC Advil for the pelvic pain, with minimal relief in symptoms.
Past Med. Hx (PMH):
Medical:
No significant medical history
Surgical:
No surgical history
Hospitalizations:
2 vaginal deliveries 10 and 8 years ago
Childhood Illness/Accidents:
None
Allergies:
NKDA, environmental, or food allergies
Immunizations:
Current on all immunizations
Flu vaccine 10/2023
Received 3 doses of HPV vaccine
Medications:
Patient does not take any prescription medications, vitamins, or supplements
Does not use hormonal birth control, uses male condoms
GYU/Sexual
LMP: February 1, 2024
Periods last 4-5 days, without heavy bleeding
28 day cycle, patient states her periods are regular
Onset of menarche age 12
G2P2
Both normal spontaneous vaginal deliveries 10 and 8 years ago without any complications
Number of lifetime partners:
6
Patient is heterosexual, married
Sexual Behaviors:
Pt engages in vaginal intercourse only
Sexually active with her husband of 10 years
STI Hx:
Denies any history or symptoms of STIs
Family Hx:
Mother: alive age 54, healthy, no cancer history
Father: alive age 55, HTN, HLD
Maternal grandmother: died at age 79 from CVA, no cancer history
Maternal grandfather: died at age 80 MI
Paternal grandmother: alive age 75, healthy
Sister: alive age 25 healthy
Social Hx:
Lives in a house with her husband and two children. Works part-time as a dental assistant. The patient denies using illicit drugs, smoking, or consuming alcohol. She tries to stay active by attending yoga classes 3-4 times per week. She eats a balanced diet, mostly home-cooked meals. She denies any history of anxiety or depression.
Review of Systems (ROS)
General: Negative for fever, chills, excessive fatigue, or stress. Denies recent weight gain or loss, or changes in appetite
HEENT: Negative for visual disturbance, nasal congestion, or sore throat. Denies facial swelling
Endocrine: Negative for thyroid disorders
Cardiac: Negative for chest pain or palpitations, or swelling in arms or legs
Respiratory: Negative for shortness of breath or difficulty breathing
Integumentary: Negative for unusual moles or rashes
Breast: Negative for pain or lumps
Lymphatic: Negative for swelling in lymph nodes
GI: Negative for recent N/V/D, constipation, abdominal cramping or tenderness
GU: Negative for retention, pain, burning, presence of blood when urinating
GYN: Positive for pelvic pain and vaginal bleeding & spotting in between menses. Negative for vaginal discharge, odor, or itching.
Musculoskeletal: Negative for joint weakness or pain
Neuro: Negative for recent headache, dizziness, or numbness/tingling in extremities
Health maintenance:
Last Pap: May 2023 Normal
Never had a mammogram, not currently due based on guidelines
Objective
Vital signs: BP 120/80, HR 65, RR 18, Temp 98.6F, Height: 56:, Weight: 130lbs, BMI: 21.0
General appearance: A&Ox4, vital signs stable, no indicators of acute distress at time of visit. Well-developed and nourished individual.
HEENT: Normocephalic, atraumatic, no abrasions or bruising present, no oral lesions present, thyroid midline with no tenderness or nodules noted.
Respiratory: Chest rise equal. Lungs clear to auscultation bilaterally anterior/posterior, no adventitious breath sounds present
Cardiac: S1, S2 no murmurs, rubs, or gallops noted
Integumentary: No rashes or abnormal moles noted on visualized skin
Lymphatic: lymph nodes not palpable or tender
Breasts: Breasts are symmetrical bilaterally, no dimpling, nipple inversion, discharge or bleeding noted bilaterally including the tail of Spence. No lymphadenopathy noted.
GI: soft, non-tender, non-distended, round. Bowel tones normoactive in all 4 quadrants
GYN/GU: Upon palpation there is a firm, raised area on the left side of the uterus with an irregular contour, measuring approximately 12 weeks. The uterus is midline and mobile. No CMT or adnexal tenderness present. Urethra is midline and the urethral meatus is without prolapse, no bladder tenderness noted. The external genitalia is without erythema or lesions. Cervix is pink and without discharge. No cystocele or rectocele noted.
Urine pregnancy test done at time of visit: negative
Musculoskeletal: Full ROM in all extremities, stable gait pattern
Neuro: Mood and affect appropriate during visit.
Assessment (Diagnosis/ICD10 Code)
Primary Diagnoses
D25.9 Leiomyoma of uterus, unspecified
Discussion: Uterine fibroids (leiomyomas) are the most common pelvic tumor in females aged 35-49 years of age (Stewart & Laughlin-Tommaso, 2023). They are even more common in African American females, being present in 59% of those surveyed in a study (Stewart & Laughlin-Tommaso, 2023). Some patients may be asymptomatic, but others may develop symptoms as the fibroid grows in size (Stewart, 2024). There are several risk factors associated with the prevalence of developing uterine fibroids. Multiple pregnancies, early menarche, use of hormonal contraception, obesity, alcohol use, high blood pressure, chronic stress, race, and high consumption of red meats have all been linked to increased risks of developing fibroids (Stewart & Laughlin-Tommaso, 2023). Common symptoms include heavy/prolonged menstrual bleeding, pelvic pressure and pain, and miscarriage and infertility (Stewart & Laughlin-Tommaso, 2023). The patient in this case has pertinent positives of pelvic pain. Although she denies heavy bleeding, she does have bleeding/spotting occurring in between her menses. Additional diagnostics, such as a pelvic ultrasound are necessary to make a definitive diagnosis.
Differential Diagnosis
C55 Malignant neoplasm of uterus, part unspecified
Discussion: Abnormal uterine bleeding is the primary symptom of endometrial cancer (Chen & Berek, 2024). While Donna does present with abnormal vaginal bleeding, her age puts her in the lower risk factor having endometrial cancer, as it is most common in those aged 55 and older (Chen & Berek, 2024). A biopsy is still indicated for Donna, as there is a presence of a mass on her uterus upon examination. The biopsy can be used to determine if malignancy is present.
Plan
Dx Plan (lab, x-ray)
Pelvic ultrasound
Discussion: A pelvic ultrasound is the initial imaging that is ordered when suspecting and diagnosing uterine fibroids (Stewart & Laughlin-Tommaso, 2023). This allows visualization of all the organs within the pelvic cavity and will show if there is an abnormality or growth.
Transvaginal ultrasound
Discussion: A transvaginal ultrasound is useful in visualizing the precise location of the uterine fibroid (Stewart & Laughlin-Tommaso, 2023).
Saline infusion sonography
Discussion: A saline infusion sonography is indicated if the provider suspects submucosal and intramural myomas (Stewart & Laughlin-Tommaso, 2023).
Possible MRI
Discussion: Depending on the findings of the above diagnostics, an MRI could help differentiate between leiomyomas, adenomyomas, and adenomyosis (Stewart & Laughlin-Tommaso, 2023).
A biopsy is also indicated to rule out malignancy. Depending on where in the uterus the mass is located, the patient may require either a hysteroscopy-guided biopsy or an ultrasound-guided biopsy (Stewart, 2024).
Medications/Supplements
Combined estrogen/progestin contraceptives can help regulate the vaginal bleeding/spotting in between menses, and be offered as an oral pill, vaginal ring, or transdermal patch (Stewart, 2024).
OTC pain relievers, such as Ibuprofen 400mg PO q4-6hr PRN, or Acetaminophen 325mg PO q4-6hr PRN
Education, including specific medication teaching points:
Monitor your symptoms closely. Immediately report to the provider if there is an increase in pelvic pain, an increase in vaginal bleeding, constipation, or urinary retention as these can indicate that the fibroid is growing.
Depending on the size and severity of symptoms, some patients may be recommended watchful waiting. However, since this patient does have bothersome symptoms, she should be encouraged to start treatment for symptom management. Hormonal therapy is the least invasive out of all the current options and should be attempted first.
Another treatment option is uterine artery embolization. This is appropriate for patients who are premenopausal and no longer wish to have children (Stewart, 2024). The procedure is minimally invasive and has a nearly 90% success rate in patients stating that their symptoms have improved or resolved (Stewart, 2024).
Some complications that can occur if the patient doesnt comply with the treatment regimen include worsening pelvic pain and vaginal bleeding, the continued growth of the fibroid leaking to heavier vaginal bleeding, and possible anemia. Fertility issues can arise from the growing fibroid should the patient wish to become pregnant again. The most significant consequence is missing the detection of a potential cancer.
Referral/Follow-up
If a biopsy comes back positive for malignancy, the patient will be referred to a GYN oncologist for a more tailored treatment plan and surgical intervention.
Schedule a follow-up in two weeks to review the results of diagnostic tests, and discuss treatment options.
Health maintenance (including when screenings, immunizations, etc., are next due):
Level A recommendations include:
Cervical cancer, HIV, HTN, and syphilis screenings (United States Preventive Services, 2023).
Next Pap due: May 2024
Level B recommendations include:
Anxiety, depression, & suicide risk screenings, BRCA-related cancer risk assessment, breast cancer, chlamydia & gonorrhea, Hepatitis B & C, IPV, STIs, osteoporosis screenings; healthy diet and exercise for cardiovascular disease prevention, intimate partner violence, and STI prevention screenings (United States Preventive Services, 2023).
2 Case Scenario 2
Table 1
Definition and how does this test work
What medical conditions or diagnoses are best suited for this test
Any special considerations or instructions prior to or during the test
Pelvic Ultrasound- Abdominal Ultrasound
Definition – looks at organs in pelvic area between abdomen and legs
How it works gently presses device against abdomen and signals it to a computer creating an image of the structures in the abdomen (Dietrich, 2024).
Tumor, infections, inflammatory syndrome and cancer (Dietrich, 2024).
Do not drink or eat anything after midnight. 2 hours prior to scheduled exam drink 1 quart of water (Dietrich, 2024).
Pelvic Ultrasound- Transvaginal Ultrasound
Definition a more complete evaluation of ovaries, uterus, and pelvic regions
How it works The transducer uses sound waves to create images (Shobeiri, 2024).
Cysts, fibroid tumors, or other growths (Shobeiri, 2024).
Drink 32 ounces of any liquid one hour before your examination. Try to drink all the liquid in under 30 minutes and arrive to exam with full bladder (Shobeiri, 2024).
Saline infusion Sonohysterography
Definition Fluid instilled in the uterine cavity; this will provide endometrial visualization
How it works This uses a small amount of saline inserted into the uterus (Goldstein, 2024).
Polyps, Hyperplasia, adhesions, and focal lesions (Goldstein, 2024).
This should not be performed on a woman who is pregnant or who is going to be pregnant (Goldstein, 2024).
Hysteroscopy
Definition allows surgeon to look inside uterus and cervix
How it works A thin light tube that is inserted inside into the cervix to examine the uterus (Bradley, 2024).
Heavy menstrual bleeding, uterine septa, endometrial polyps, and irregular spotting (Bradley, 2024).
Active pelvic infection, genital herpes, and endometrial cancer (Bradley, 2024).
HSG- hysterosalpingogram
Definition imaging preformed to assess the causes of infertility in women
How it works uses a radiopaque dye that is injected into the uterus and is visualized with an x-ray (Lee, 2024).
To see fallopian tubes and if they are fully blocked (Lee, 2024).
This should take place at least 7-10 days after beginning last menstrual period (Lee, 2024).
Laparoscopy
Definition check the organs in the abdomen and pelvic organs
How it works thin tube that explores abdominal cavities and pelvic cavities (Pryor, 2024).
Appendicitis, endometrial cancer, and liver cancer (Pryor, 2024).
Do not eat, drink, or smoke the night before the surgery (Pryor, 2024).
Endometrial Biopsy (EMB)
Definition tissue sample is obtained from the endometrium and examined under microscope
How it works Collecting a small part of the endometrial lining and examining it (Priore, 2024).
Abnormal uterine bleeding, postmenopausal bleeding, and cancer (Priore, 2024).
Do not douche, have sex, or use tampons for 2 to 3 days after biopsy (Priore, 2024).
Colposcopy
Definition examines cervix, vagina, and vulva
How it works This will be used as a magnifying instrument and the vagina with cervix will be swabbed (Colleen, 2024).
Cancerous, warts, cervix, and vagina (Colleen, 2024).
Do not put any ointment of cream onto vagina (Colleen, 2024).
Endocervical Curettage (ECC)
Definition narrow instrument called a curette to scrape the lining of the endocervical canal.
How it works small instruments used to dilate the cervix an a small instruments used to cut tissue (Braateen, 2024).
Precancer or cancer of the cervix (Braateen, 2024).
This procedure is acceptable for nonpregnant patients (Braateen, 2024).
Dilation and curettage (D&C)
Definition removing tissue samples from cervix
How it works small instruments used to dilate the cervix an a small instruments used to cut tissue (Braateen, 2024).
Miscarriage, abortion, or post pregnancy bleeding (Braateen, 2024).
Do not douche, have sex, or use tampons for 2 to 3 days after D&C (Braateen, 2024).
Case 2
Subjective:
Chief Complaint: 35 y/o female complains pelvic pain that started out as intermittent and is now constant. Also, irregular vaginal bleeding/spotting that has occurred in between monthly menses for the last 6 months
HPI: 35 y/o female present to the clinic for pelvic pain that started out as intermittent and is now constant. Reports irregular spotting/bleeding that has occurred in between monthly menses for the last 6 months. Denies SOB or cramping.
Relevant questions should ask regarding HPI? How often is the constant pelvic pain? What would you rate that pain on a scale of 0-10? Is it a sharp pain? Have you ever experienced something like this? When did this pain develop?
Other medical questions? Do you have any fever? Are you experiencing nausea? Have you had your hormone levels checked? Have you had any change in bowel habits? Frequency?
Social questions? When did you last take a pregnancy test? Do you have any history with STDs? Do you have any history with fibroids? Have you gotten a pelvic ultrasound? Have you had any previous cysts? Do you use contraceptives? If so how long?
Family history? Do you have any family history with cysts or fibroids? When did your mother start menopause?
PMH: G2P2 NSVD
Past Surgical Hx: Appendectomy
Allergies: Morphine
Family Hx:
Daughter, 10, Alive
Son, 8, Alive
Husband, 37, Alive
Mother, 66, Alive, Diabtetes
Father, 67, Alive, HTN
Brother, 43, Alive, Epileptic
Maternal Grandmother, 89, Alive, Hashimotos
Maternal Grandfather, 87, Alive, Dementia
Paternal Grandmother, 88, Deceased, Gun Shot
Paternal Grandfather, 85, Deceased, Stab Wound
Social Hx:
Occupation Lawyer
Alchohol Drinks 1 alcoholic drink/week preferably a glass of wine
Substance Abuse No hx of substance abuse
Subjective Data:
General/Constitutional:
Denies malaise, weakness, fever, or chills. Denies recent weight gains or losses of >20 pounds over the last 6 months.
Cardiovascular:
Denies chest discomfort, heaviness, or tightness. Denies abnormal heartbeat or palpitations. Denies shortness of breath, denies having to sleep elevated on 2 pillows or more, no swelling of the feet, no passing out or nearly passing out. Denies history of heart attack or heart failure.
Respiratory:
Denies cough, phlegm production, coughing up blood, wheezing, sleep apnea, exposure to inhaled substances in the workplace or home, no known exposure to TB or travel outside the country. Denies history of asthma, COPD/emphysema or any other chronic pulmonary disease.
Gastroinestinal:
Denies nausea, vomiting, abdominal discomfort/pain. Denies diarrhea, constipation, blood in the stool or black stools. Denies hemorrhoids, trouble swallowing, heartburn or food intolerance. Denies history of liver or gallbladder disease. No recent weight gains or losses of > 20 pounds within the last year.
Skin and Breasts:
Denies rash, itching, abnormal skin, or recent injury. Denies breast pain, discharge, or other abnormality was reported by the patient.
Genitourinary:
Denies Abdominal pain/swelling. Denies Blood in urine. Denies Difficulty urinating. Denies Frequent urination. Denies Pain in lower back.Denies Painful urination
Women Only:
Irregular vaginal bleeding/spotting that has occurred in between her monthly menses for the last six months
Mental Status/Psychiatric:
Denies history of depression or anxiety. Denies difficulty sleeping, persistent thoughts or worries, decrease in sexual desire, abnormal thoughts, visual or auditory hallucinations. Denies history of psychosis or schizophrenia. Denies difficulty concentrating or change in memory.
Up to date on all Immunization
Endorses a male sexual partner
Objective:
VS: BP: 120/82, HR: 70, RR: 18, Temp: 99.1,O2 Sat: 97%, HT 56 inches WT: 155lb
Physical Exam:
General: Alert and Oriented x4, speaks clearly and comfortably throughout.
BREAST: normal breast exam, Breasts, BL: no abnormalities, (-) erythema, (-) symmetric at rest, (-) symmetric with pectoral tension, (-) tender to palpation
Nipples, BL: no abnormalities, (-) discharge without pressure, (-) expressed discharge, (-) clear discharge, (-) bloody discharge, (-) purulent discharge, (-) bruising, (-) areolar bleeding
Axillae BL: no abnormalities, (-) mass, (-) tender to palpation, (-) erythema, (-) pectoral lymphadenopathy, (-)subscapular lymphadenopathy, (-)brachial lymphadenopathy, (-)acanthosis nigricans
RESP: lungs clear to auscultation bilaterally, no rales, wheezes or rhonchi, nonlabored breathing, no use of accessory of muscles of respiration.
CV: RRR
Urethral meatus: (-)lesions, (-) erythematous, (-)discharge, (-)tender
Bladder: normal, (-)tender, (-)cystocele
Vagina: appearance, pelvic support, (-)discharge, (-)lesions, (-) fluid filled vesicles painful to touch
Cervix: (-)lesions, (-)discharge, (-) contact bleeding,
Uterus: firm, raised, (+)enlarged (-)tender, (-) cervical motion tenderness
Adnexae, BL: no abnormalities, (-)tender, (-)masses, (-)enlarged,
Anus/rectum: no abnormalities, tone, (-)perianal lesions, (-)external hemorrhoids,
Rectal exam deferred: not indicated
Extremities: (-) edema
DERM: skin warm and dry
Tests will order:
STD panel negative
CBC unremarkable
Labs, progesterone, estrogen, and testosterone pending results
Pelvic Ultrasound pending results
Pap Smear pending results
Assessment:
Diff Dx:
N80. 9: Endometriosis, unspecified
The pertinent positives spotting between periods and pelvic pain
The pertinent negatives painful menstrual cramps, pain during sex
N80. 03 Adenomyosis of the uterus
The pertinent positives prolonged menstrual bleeding and cramps
The pertinent negatives blood clots throughout menstrual cycle
Final Diagnosis:
D25.9 Leiomyoma of uterus
The Pertinent positive includes spotting between periods, pelvic pain, enlarged uterus
The Pertinent negative includes weakness and weight gain
Plan:
Treatment Plan: The diagnostic test to confirm the diagnosis is a pelvic ultrasound. Specifically, a transvaginal ultrasound or MRI. Saline Infusion Sonohysterography can help in assisting a diagnosis of a discrete uterine fibroid (GoldStein, 2024). This is fluid instilled in the uterine cavity; this will provide endometrial visualization. Some fibroids can improve based on diet, changes in exercise, and stress management. Medical management will be used as treatment such as NSAID, low dose oral contraceptive, estrogen therapy, and fibrinolytics (Alexander, 2017). On top of NSAIDs utilize a heating pad for cramps. A progestin releasing IUD might also help. The need for surgical intervention is based on bleeding. Since this is only happened within the last 6 months surgical intervention is not necessary. If needed it would involve operative hysteroscopy. This is the removal of the uterine fibroids. The side effects of this surgery is scar tissue, blood clots, heavy bleeding, and infection.
Education: These fibroids are most common in 80% black females (Stewart, 2024).
Leiomyoma of the uterus can cause pelvic pain. These are benign neoplasms that can develop into smooth muscle pelvic masses and grow to be enlarged (Alexander, 2017). The diagnostic test to confirm the diagnosis is a pelvic ultrasound. Specifically, a transvaginal ultrasound or MRI. The transvaginal ultrasound will help to see more surrounding structures needed than just the pelvic ultrasound. It is important to act quickly when diagnosing a fibroid because some if not a fibroid then it may be cancerous. The sooner the diagnosis the better. Studies have shown that prolonged exposure to estrogen might cause fibroids to develop. Fibroids are also very common. Foods to avoid if one does have fibroids are dairy, sugar, and processed meats. Increase Vitamin D, legumes, omega 3, and fresh fruit (Stewart, 2024). Cut back on alcohol and smoking, this will increase risk. The complication that can occur of the regimen goes ignored that the bleeding can cause anemia, the fibroids can grow causing a tumor, pain will increase, and infertility.
Referral/Follow-up: f/u for transvaginal pelvic US results and lab results
Recommend a Pap Smear every 3 years to rule out cervical cancer and US if pelvic pain
