Endometriosis
The most likely diagnosis is endometriosis (option c). This patient's presentation of progressively worsening menstrual pain over 2 years that begins before menstruation and continues after bleeding stops, combined with infertility, is classic for endometriosis 1, 2.
Key Diagnostic Features Present
The clinical presentation demonstrates the hallmark pain patterns of endometriosis:
- Progressive worsening over time - Endometriosis is a chronic, estrogen-dependent inflammatory disease that characteristically worsens progressively during reproductive years 1, 3, 4
- Pain timing extending beyond menstruation - The pain beginning before menses and continuing after bleeding stops is typical of secondary dysmenorrhea from endometriosis, distinguishing it from primary dysmenorrhea which is limited to the menstrual period 1, 2
- Associated infertility - Approximately 50% of patients with endometriosis present with infertility, and the condition affects at least one-third of women with infertility 2, 5, 4
Why Other Options Are Less Likely
Primary dysmenorrhea (option d) is excluded because:
- Primary dysmenorrhea does not progressively worsen over years 1
- Primary dysmenorrhea is not associated with infertility 6
- Pain in primary dysmenorrhea is confined to the menstrual period, not extending before and after as described 1
Chronic pelvic inflammatory disease (option a) is less likely because:
- PID typically presents with acute or subacute symptoms rather than progressive worsening over 2 years 7
- The specific pattern of pain related to menstrual timing is not characteristic of chronic PID 7
Adenomyosis (option b) is possible but less likely because:
- Adenomyosis typically affects older reproductive-aged women and is more common in multiparous women 2
- While adenomyosis can cause progressive dysmenorrhea, the combination with infertility and the specific pain timing pattern is more characteristic of endometriosis 2, 4
Clinical Implications
Diagnosis can be made clinically without surgery - The American College of Radiology confirms that endometriosis diagnosis is fundamentally clinical and does not require surgical confirmation before initiating empiric treatment 2. Laparoscopy with histologic confirmation is no longer required before starting therapy 2.
Initial imaging approach - Transvaginal ultrasound with expanded protocol is the recommended first-line imaging modality, with sensitivity of 82.5% and specificity of 84.6% for detecting endometriosis 2. MRI pelvis should be considered if ultrasound is inconclusive or for surgical planning 2.
Treatment should not be delayed - First-line treatments include hormonal medications such as combined oral contraceptives and progestin-only options 1. Medical treatment is generally effective for pain management, though it does not enhance fertility and conception is not possible during therapy 6, 3.