Differential Diagnosis for New-Onset Pain with Intercourse
- Single Most Likely Diagnosis
- Polycystic Ovary Syndrome (PCOS): The patient's symptoms of dyspareunia, vaginal dryness, and the presence of a large adnexal mass, along with the physical examination findings of atrophic breasts, pale and thin vulvae, and a protruding clitoris, are suggestive of hormonal imbalance. PCOS is a common endocrine disorder in women of reproductive age and can cause these symptoms due to androgen excess and estrogen deficiency.
- Other Likely Diagnoses
- Hypogonadism or Premature Ovarian Failure: The patient's symptoms of vaginal dryness and dyspareunia, along with the physical examination findings, could also be indicative of hypogonadism or premature ovarian failure. The family history of a sister with infertility due to 45,X mosaicism (Turner syndrome) increases the likelihood of genetic or hormonal disorders affecting the patient.
- Ovarian Tumor: The presence of a large, solid adnexal mass on pelvic ultrasound is concerning for an ovarian tumor, which could be benign or malignant. The mass could be causing the patient's symptoms due to local effects or hormonal production.
- Do Not Miss Diagnoses
- Ovarian Cancer: Although less likely given the patient's age, ovarian cancer is a critical diagnosis that must not be missed. The presence of a large adnexal mass and the patient's symptoms warrant further investigation to rule out malignancy.
- Endometriosis: While the patient does not have postcoital spotting or abnormal vaginal discharge, endometriosis can cause dyspareunia and adnexal masses. It is essential to consider this diagnosis, especially given the patient's age and symptoms.
- Rare Diagnoses
- Androgen Insensitivity Syndrome: This rare genetic disorder could explain the patient's physical examination findings, such as a protruding clitoris and atrophic breasts. However, it is less likely given the patient's reported normal female development and absence of other typical features.
- Swyer Syndrome: Another rare genetic disorder, Swyer syndrome, could be considered, especially with the family history of Turner syndrome. However, this diagnosis is less likely without additional features such as primary amenorrhea.