A 19-year-old woman comes to the office for evaluation of dyspareunia. The patient became sexually active with her boyfriend 4 months ago but has been avoiding intercourse for the past month because it has become too painful. She has tried using a water-based lubricant during intercourse, but it has not relieved her pain. The patient is using condoms for contraception. She has regular menses with 3-4 days of heavy bleeding and lower abdominal cramping. There has been an increase in cramping over the past 2 months but no abnormal vaginal discharge. The patient has type 1 diabetes mellitus and uses an insulin pump; her most recent hemoglobin A1c was 7.2%. Vital signs are normal. BMI is 21 kg/m². On pelvic examination, the vulva and cervix appear noninflamed. Speculum examination reveals a laterally displaced cervix. Bimanual examination reveals a small uterus with cervical motion tenderness. Which of the following is the most likely cause of this patient's dyspareunia?

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11ec25c8_d9bf_b82a_bc81_c1afdc96dd61_MD0003_00 This patient with dyspareunia and worsening menstrual cramping most likely has endometriosis, ectopic endometrial implants within the intraabdominal cavity. These ectopic glands and stroma proliferate and shed within the abdominal cavity during menses; however, because there is no outlet, patients develop intraabdominal inflammation and fibrosis, causing dysmenorrhea (ie, increase in cramping during menses). ectopic endometrial implants Depending on the location of the lesions, patients may also experience dyspareunia (ie, pain with intercourse) due to proximity of the vagina to the internal pelvic structures (eg, uterus, bladder, rectum). Therefore, on examination, patients may have cervical motion tenderness. With continued inflammation, patients can also develop intraabdominal fibrosis and adhesions causing pelvic anatomy distortion, as seen in this patient's lateral cervical displacement. Treatment options for symptomatic patients include nonsteroidal anti-inflammatory drugs, combination oral contraceptives, and surgical resection. (Choice A) Patients with diabetes mellitus are at higher risk for Candida albicans vulvovaginitis, which may cause dyspareunia. However, it typically presents with vulvovaginal erythema and a thick, white vaginal discharge, which are not seen in this patient. Candida albicans vulvovaginitis (Choice C) Genito-pelvic pain/penetration disorder (also called vaginismus) is pain caused by vaginal penetration only, possibly due to involuntary contraction of pelvic floor muscles. It does not cause worsening menstrual cramping or a displaced cervix. (Choice D) Pelvic inflammatory disease can cause dyspareunia and cervical motion tenderness; however, this patient has no fever or concomitant cervical inflammation (ie, cervicitis), making this diagnosis less likely. In addition, she has worsening pain with menses not typical of pelvic inflammatory disease. (Choice E) Uterine leiomyomata (fibroids) can cause heavy menstrual bleeding and cervical displacement (from large, bulky fibroids). The patient's small uterus makes this diagnosis unlikely. In addition, fibroids do not typically cause cervical motion tenderness and are uncommon in teenagers. Uterine leiomyomata (fibroids) (Choice F) Vulvodynia can cause painful intercourse; however, patients have pain of the surrounding external genitalia (eg, vulva) only. Therefore, they do not have dysmenorrhea, cervical motion tenderness, or cervical displacement. Educational objective: Endometriosis, ectopic endometrial tissue implants within the intraabdominal cavity, can cause chronic inflammation and fibrosis. Therefore, patients can develop chronic pelvic pain (eg, cervical motion tenderness), dysmenorrhea, dyspareunia, and distorted pelvic anatomy (eg, cervical displacement). References: Clinical practice: endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/20573927) Endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/20573761) Endometriosis and the adolescent. (http://www.ncbi.nlm.nih.gov/pubmed/20436319)

A 19-Year-Old Woman Comes to the Office for Evaluation of Dyspareunia