Endometriosis (Option A)
The diagnosis is endometriosis, which classically presents with the combination of chronic dysmenorrhea and infertility in reproductive-aged women. 1, 2
Clinical Reasoning
Why Endometriosis is the Answer
- Endometriosis affects at least one-third of women with infertility and up to 10% of reproductive-aged women, making it the most likely diagnosis when these two symptoms coexist 2
- The classic triad of endometriosis pain includes secondary dysmenorrhea, deep dyspareunia, and sacral backache with menses 1
- Infertility occurs in 20-30% of women with endometriosis and can be the only presenting symptom alongside pelvic pain 3
- The fecundity rate of untreated women with endometriosis is lower than normal couples, establishing the clear link between this condition and reproductive difficulty 4
Why Not the Other Options
Endometritis (Option B):
- Endometritis is an acute or chronic infection of the endometrial lining, typically presenting with fever, abnormal vaginal discharge, and acute pelvic pain 5
- It does not characteristically cause years of chronic dysmenorrhea or primary infertility as the main presentation
- The time course ("years") strongly argues against an infectious process
Leiomyomata/Fibroids (Option C):
- While fibroids can cause dysmenorrhea and may contribute to infertility, they are focal masses that distort uterine contour rather than causing the diffuse inflammatory process typical of endometriosis 6
- Fibroids more commonly present with heavy menstrual bleeding (menorrhagia) rather than painful menses as the primary complaint
- The combination of infertility with dysmenorrhea is more characteristic of endometriosis than fibroids alone
Diagnostic Approach
Clinical Diagnosis
- Diagnosis in primary care is clinical and does not require immediate surgical confirmation 7
- Several gynecologic organizations recommend empiric therapy without immediate surgical diagnosis 7
- Look for: dysmenorrhea, dyspareunia, period-related gastrointestinal or urinary symptoms, and infertility 7
Imaging When Needed
- Transvaginal ultrasound is the initial imaging modality to evaluate for endometriomas and assess ovarian reserve 2, 6
- MRI has high sensitivity (82-90%) and specificity (91-98%) for detecting endometriomas when ultrasound is indeterminate 2
- Laparoscopy with biopsy remains the definitive diagnostic method, though it's reserved for cases where empiric therapy fails or immediate diagnosis is necessary 2, 7
Common Pitfall
Do not delay treatment waiting for surgical confirmation—empiric hormonal therapy should be initiated based on clinical presentation alone, as diagnostic delay is a frequent problem with endometriosis management 7