What could be causing a female patient of reproductive age to experience cramping pain similar to menstrual cramps upon sexual arousal?

Cramping Pain with Sexual Arousal in Reproductive-Age Women

The most likely causes are uterine contractions during arousal (a normal physiological response), endometriosis, adenomyosis, or pelvic congestion syndrome, with the differential broadening to include pelvic inflammatory disease, ovarian cysts, or uterine fibroids depending on additional symptoms.

Immediate Assessment Priorities

• Obtain serum beta-hCG immediately to exclude pregnancy-related causes, as pregnancy status fundamentally changes the diagnostic approach 1
• Determine if pain is cyclical (hormonal/menstrual-related) versus non-cyclical, as this narrows the differential significantly 2
• Assess for deep pelvic pain versus perineal/vulvar/vaginal pain to localize the source 3, 1

Most Likely Gynecologic Causes

Primary Considerations

• Endometriosis is a leading cause of chronic pelvic pain in reproductive-age women and commonly causes pain with sexual activity due to deep infiltrating lesions 3, 1
• Adenomyosis causes chronic pelvic pain and dyspareunia through uterine muscle involvement 3, 1
• Pelvic congestion syndrome (pelvic venous disorders) presents with engorged periuterine and periovarian veins that can cause pain during arousal when pelvic blood flow increases 3, 4
• Ovarian cysts are the most common gynecologic cause of acute pelvic pain in reproductive-age women and can cause cramping with increased pelvic pressure during arousal 1, 5

Secondary Considerations

• Pelvic inflammatory disease accounts for 20% of pelvic pain cases and should be assessed through sexual history and recent instrumentation 1
• Uterine fibroids can cause cramping, particularly if pedunculated or undergoing degeneration 5
• Intraperitoneal adhesions may be associated with chronic pain, though causal linkage remains unclear 3

Non-Gynecologic Causes to Exclude

• Interstitial cystitis frequently masquerades as gynecologic pain and presents with chronic pelvic pain, urgency, frequency, and nocturia 6
• Pelvic myofascial pain can cause cramping sensations with increased pelvic muscle tension during arousal 3
• Inflammatory bowel disease should be considered if gastrointestinal symptoms coexist 3

Diagnostic Approach

First-Line Imaging

• Transvaginal and transabdominal ultrasound combined is the first-line imaging modality, with transvaginal providing superior resolution for pelvic structures 1
• Include color and spectral Doppler to evaluate internal vascularity and distinguish cysts from soft tissue 1
• Doppler ultrasound can identify pelvic varices in pelvic congestion syndrome 4

Second-Line Imaging

• MRI pelvis is first-line when endometriosis or fistulizing disease is specifically suspected based on clinical presentation 1
• MRI can demonstrate varices in the pelvis, vaginal wall, and perineum if pelvic congestion syndrome is suspected 4
• CT abdomen/pelvis with IV contrast is recommended when ultrasound findings are equivocal, with 89% sensitivity versus 70% for ultrasound alone 1

Critical History Elements

• Sexual and trauma history using a trauma-informed approach, as sexual assault predisposes to chronic pelvic pain syndromes 2
• Timing of pain relative to menstrual cycle to distinguish cyclical versus non-cyclical patterns 2
• Associated symptoms including dysmenorrhea, menorrhagia, or sexual dysfunction 2
• Medication history, particularly hormonal medications, oral contraceptives, and SSRIs that can cause pelvic pain 2

Treatment Considerations

• Refer to gynecologic specialist for evaluation if endometriosis, adenomyosis, or significant dysmenorrhea is suspected, with consideration for laparoscopy evaluation 2
• Pelvic floor physical therapy is first-line treatment for genito-pelvic pain disorders 7, 8
• Cognitive behavioral therapy is first-line for disorders of sexual desire and arousal that may contribute to pain 7, 8
• Consider coil embolization if pelvic congestion syndrome is confirmed on imaging 4

Common Pitfalls to Avoid

• Do not assume gynecologic origin without systematically evaluating gastrointestinal, urologic, and musculoskeletal systems, as 15-25% of pelvic pain has non-gynecologic causes 1, 5
• Do not skip pregnancy testing even if the patient reports contraceptive use or recent menses 1
• Do not overlook interstitial cystitis, as gynecologists rarely consider the bladder as a source of pelvic pain despite its frequency 6
• Do not dismiss as "normal" without proper workup, as early diagnosis and treatment improve prognosis and quality of life 6