Dolor

A 35 year old G4P4 woman presents with chronic pelvic pain, your favorite chief complaint. This has been going on for years. It began with her second pregnancy and worsened with each subsequent pregnancy. It's a dull ache or heaviness that increases premenstrually. It is exacerbated by prolonged standing, postural changes, walking, coughing, and after intercourse. It is mostly on the left side. A bimanual examination shows marked ovarian tenderness, cervical motion tenderness, and uterine tenderness with direct palpation.

She's seen multiple physicians. Pelvic sonograms have only shown dilated pelvic veins in the adnexa and outer myometrium. CT scans have only showed tortuous and dilated ovarian veins. A left ovarian venogram is shown above. She's even had a diagnostic laparoscopy that was normal. She's been treated with opiates, antibiotics, steroids, and other medications. The only thing that has benefited has been medroxyprogesterone acetate.

Challenge: What's your diagnosis?

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