A 23-Year-Old Nulligravid Woman Comes to the Office for Evaluation

A 23-year-old nulligravid woman comes to the office for evaluation of dyspareunia.  The patient reports a year-long history of increasing dyspareunia and has not been sexually active for the last 3 months due to pain on penetration.  The pain is deep in the pelvis and becomes intolerable, causing her to become tense during intercourse.  The pain is not relieved with water-based lubricants.  The patient became sexually active at age 19 and has had 4 lifetime partners.  She had gonococcal cervicitis at age 20.  She has no chronic medical conditions and has never had surgery.  Menarche was at age 14 and menstrual periods are regular.  The patient has painful cramping with menses that requires nonsteroidal anti-inflammatory drugs for the first 3 days of her menstrual period as well as the day prior.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98 F) , blood pressure is 110/80 mm Hg, and pulse is 76/min.  BMI is 22 kg/m².  Pelvic examination reveals normal external genitalia with no tenderness to palpation.  The cervix has no lesions and no discharge.  There is mild tenderness on bimanual examination of the uterus; no adnexal masses are palpated.  Transvaginal ultrasound reveals a small, anteverted uterus with no adnexal masses.  Which of the following is the best next step in management of this patient?

A) Azithromycin plus ceftriaxone
B) Combination oral contraceptives
C) Pelvic floor physical therapy
D) Progressive vaginal dilation
E) Topical lidocaine ointment