A 26-year-old nulliparous woman comes to the office due to severe pain during sexual intercourse. The pain is "particularly unbearable" with deep penetration, which has caused the patient to avoid sexual intimacy for the past few months. This has placed a significant strain on her relationship with her husband of 2 years, who has been her only sexual partner. They have been using condoms with lubrication during intercourse, but this has not improved the pain. Menses occur every 30 days, are painful, and last for 5 days with moderate bleeding. The patient has no chronic medical conditions and takes no daily medications. BMI is 24 kg/m². Vital signs are normal. Speculum examination is normal. Which of the following is the most appropriate treatment for this patient's condition?

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11ec25c8_d9bd_6e35_bc81_d1fb0cc1248c_MD0003_00 This patient with severe dyspareunia and dysmenorrhea likely has endometriosis, ectopic implants of endometrial glands and stroma in the abdomen and pelvis. Like normal endometrium, these intraperitoneal implants proliferate and shed during menses; however, because they have no outlet, endometriosis implants can cause recurrent, slowly progressive pelvic inflammation and fibrosis. The chronic inflammation, fibrosis, and subsequent adhesion formation result in the characteristic pain symptoms associated with endometriosis. Pain symptoms vary with implant location and severity; the most common pain symptoms are dysmenorrhea and severe dyspareunia (ie, pain with intercourse), particularly with deep penetration, due to the proximity of the vagina to the uterus, bladder, and rectum. implants Patients with a presumptive diagnosis of endometriosis based on clinical symptoms are initially managed with nonsteroidal anti-inflammatory drugs (which decrease inflammation) and combination oral contraceptives (which suppress ovulation and reduce menstruation). When endometriosis does not improve with medical management, surgical evaluation via laparoscopy is required for definitive diagnosis (eg, biopsy) and resection of implants. (Choices A, C, D, and E) Vaginismus, also known as genitopelvic pain/penetration disorder, is a common cause of dyspareunia. In contrast to endometriosis, vaginismus causes pain with any vaginal penetration (eg, intercourse, speculum examination). In addition, vaginismus typically causes diffuse pain due to repeated involuntary pelvic floor muscle contractions; this pain is unrelated to menses. Patients with vaginismus are typically treated with multiple modalities, including cognitive-behavioral therapy, couples therapy and sex education, pelvic floor physical therapy, and vaginal dilators. Educational objective: Endometriosis can present with dysmenorrhea and deep dyspareunia. Symptomatic patients are offered empiric medical therapy with nonsteroidal anti-inflammatory drugs and/or combination oral contraceptives, which treat inflammation and suppress ovarian stimulation of endometriosis. References: Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. (http://www.ncbi.nlm.nih.gov/pubmed/26224322) Medical treatment of endometriosis-related pain. (http://www.ncbi.nlm.nih.gov/pubmed/29530425) Clinical practice. Endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/20573927)

A 26-Year-Old Nulliparous Woman Comes to the Office Due to Severe