A 44-year-old woman comes to the office with a 6-month history of painful sexual intercourse. She has no associated itching or abnormal vaginal discharge. The patient has never had these symptoms before and has had no problems with sexual desire or orgasm. She has been monogamous with her husband for 15 years. The patient's menstrual periods are regular and are not associated with unusual pain. She has no urinary or gastrointestinal symptoms. Her medical history is notable for mild hypertension that has been well controlled with dietary changes and exercise. The patient has no history of pelvic inflammatory disease or gynecologic surgery. Her only medications include a daily multivitamin and saline eye drops for chronic dry eyes. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 36.5 C (97.7 F), blood pressure is 136/88 mm Hg, pulse is 72/min, and respirations are 12/min. The neck is supple. The patient has mild dental caries. Chest auscultation reveals no abnormalities. The abdomen is soft and nontender. Pelvic examination shows normal-appearing external genitalia and dry vaginal mucosa. The uterus and adnexa are normal with no cervical motion tenderness. Which of the following is the most likely cause of this patient's current condition?

Question

A 44-year-old woman comes to the office with a 6-month history of painful sexual intercourse.  She has no associated itching or abnormal vaginal discharge.  The patient has never had these symptoms before and has had no problems with sexual desire or orgasm.  She has been monogamous with her husband for 15 years.  The patient's menstrual periods are regular and are not associated with unusual pain.  She has no urinary or gastrointestinal symptoms.  Her medical history is notable for mild hypertension that has been well controlled with dietary changes and exercise.  The patient has no history of pelvic inflammatory disease or gynecologic surgery.  Her only medications include a daily multivitamin and saline eye drops for chronic dry eyes.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.5 C (97.7 F), blood pressure is 136/88 mm Hg, pulse is 72/min, and respirations are 12/min.  The neck is supple.  The patient has mild dental caries.  Chest auscultation reveals no abnormalities.  The abdomen is soft and nontender.  Pelvic examination shows normal-appearing external genitalia and dry vaginal mucosa.  The uterus and adnexa are normal with no cervical motion tenderness.  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d9b8_651d_bc81_41ac18f9b473_MD0003_00 Sjögren syndrome (SS) is an autoimmune disorder characterized by inflammation of the exocrine glands. It can occur as an isolated phenomenon or as a manifestation of another autoimmune disease (eg, rheumatoid arthritis). Impaired function of salivary and other exocrine glands (eg, lacrimal glands) can produce sicca syndrome, characterized by generalized dryness of mucous membranes, leading to dry mouth with increased risk of dental caries, irritated/itchy eyes, and cough. Dryness of the vaginal mucosa commonly causes dyspareunia. Extraglandular features of SS may include arthritis, Raynaud phenomenon, and cutaneous vasculitis. SS can also cause manifestations along the entire respiratory tract, including nonallergic rhinitis, bronchiectasis, large and small airway disease with impaired mucociliary clearance, and interstitial lung disease. In addition, SS is associated with a significant risk for non-Hodgkin lymphoma. (Choice A) Endometriosis causes deep dyspareunia but is unlikely in a patient without dysmenorrhea. Vaginal dryness is not a feature of this condition. (Choice B) Estrogen deficiency is a common cause of dyspareunia in postmenopausal patients. This patient is premenopausal with regular menses and does not have a lack of estrogen. (Choice D) Interstitial cystitis, also referred to as painful bladder syndrome, presents with chronic pelvic pain, urinary urgency, and dyspareunia. It is less likely to cause dry vaginal mucosa and would not affect the eyes or oral mucosa. (Choice E) Lichen sclerosis may present with dyspareunia but more typically causes vulvar itching. Physical examination findings include white vulvar plaques rather than normal external genitalia with dry vaginal mucosa. (Choice F) Vaginismus (eg, genitopelvic pain/penetration disorder) is dyspareunia due to muscle spasm that prevents vaginal penetration. Pelvic examination demonstrates involuntary muscle contraction but may be limited as muscle spasm may prevent speculum entry. (Choice G) Vulvodynia, formerly termed vestibulodynia, is a cause of painful entry dyspareunia. Physical examination shows pain to superficial touch of the vaginal vestibule rather than dryness. Educational objective: Sjögren syndrome is an autoimmune disorder characterized by inflammation of the exocrine glands. Typical features include dry mouth, autoimmune sialoadenitis, and keratoconjunctivitis sicca. Extraglandular features include arthritis, Raynaud phenomenon, dyspareunia, cutaneous vasculitis, interstitial lung disease, and non-Hodgkin lymphoma. References: Diagnosis and management of Sjögren syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/19323359)

A 44-Year-Old Woman Comes to the Office with a 6-Month