What is the appropriate evaluation and management for a reproductive‑age woman presenting with pelvic/uterine pain that worsens with intercourse (dyspareunia)?

Evaluation and Management of Pelvic Pain with Dyspareunia in Reproductive-Age Women

Begin with immediate serum or urine β-hCG testing in every reproductive-age woman presenting with pelvic pain and dyspareunia, followed by transvaginal and transabdominal ultrasound as the first-line imaging modality. 1

Initial Diagnostic Workup

Mandatory First Step: Pregnancy Testing

• Obtain β-hCG immediately in all women of reproductive age; failure to do so can result in missed ectopic pregnancy (which carries a positive likelihood ratio of 111 when an adnexal mass is present without intrauterine gestation), inappropriate radiation exposure, and increased maternal mortality risk. 1, 2
• A negative β-hCG effectively rules out pregnancy-related complications and redirects the evaluation toward non-pregnancy causes. 2

Sexual and Pain History—Specific Details to Elicit

• Characterize pain location: Entry dyspareunia (pain with vaginal insertion) versus deep dyspareunia (pain with deep penetration). 3, 4
• Timing and pattern: Cyclic pain suggests endometriosis or adenomyosis; non-cyclic pain suggests pelvic inflammatory disease, adhesions, or pelvic congestion syndrome. 5, 6
• Associated symptoms: Heavy menstrual bleeding (fibroids, adenomyosis), abnormal vaginal discharge (PID), urinary symptoms (interstitial cystitis, urethral syndrome). 3, 4, 5

Physical Examination—Targeted Findings

• External genitalia inspection with cotton-swab testing: Localized vulvar pain with light touch indicates vulvodynia (vulvar vestibulitis). 3, 4
• Single-digit vaginal examination: Involuntary pelvic floor muscle spasm suggests vaginismus; tender pelvic floor muscles indicate pelvic floor dysfunction. 3, 4
• Bimanual examination: Uterine tenderness with adnexal and cervical motion tenderness meets minimum criteria for pelvic inflammatory disease and mandates immediate empiric antibiotic therapy. 7, 2
• Palpation of lateral vaginal walls and adnexa: Reproduces deep pain in endometriosis, ovarian cysts, or pelvic adhesions. 3, 6

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Imaging Strategy

First-Line: Transvaginal and Transabdominal Ultrasound with Doppler

• Perform combined transvaginal and transabdominal ultrasound with Doppler evaluation as the initial imaging study for all patients with suspected gynecologic pathology. 1, 8
• Ultrasound demonstrates 93% sensitivity and 98% specificity for tubo-ovarian abscess, and 98% sensitivity and 100% specificity for rectosigmoid endometriosis. 2
• Key ultrasound findings by diagnosis:
  • Endometriosis: Endometrioma appears as a cystic mass with high signal intensity on T1-weighted MRI and loss of signal on T2-weighted images (MRI is definitive when ultrasound is suggestive). 6
  • Adenomyosis: Heterogeneous myometrial echotexture, asymmetric myometrial thickening, and subendometrial linear striations; MRI is the definitive modality when ultrasound is suggestive. 6
  • Pelvic congestion syndrome: Engorged periuterine and periovarian veins (≥8 mm), low-velocity flow, retrograde ovarian vein flow, and altered flow with Valsalva maneuver on Doppler. 7
  • Ovarian torsion: Unilaterally enlarged ovary (>4 cm), peripheral follicles, absent or decreased venous flow (100% sensitivity), and whirlpool sign (90% specificity). 8
  • Tubo-ovarian abscess: Thick-walled (>5 mm) complex adnexal mass, "cogwheel" sign, incomplete septations, and cul-de-sac fluid. 2

Second-Line: MRI Pelvis (When Ultrasound Is Nondiagnostic)

• Order non-contrast MRI of the pelvis when ultrasound findings are equivocal but clinical suspicion for endometriosis, adenomyosis, or pelvic congestion syndrome remains high. 1, 6
• MRI provides 80–85% sensitivity for ovarian torsion and superior soft-tissue characterization for deep infiltrating endometriosis. 8, 6
• Three-dimensional T1 gradient-echo sequences after intravenous gadolinium are most effective for demonstrating pelvic varices (high signal intensity indicates blood flow). 6

Third-Line: Contrast-Enhanced CT Abdomen and Pelvis (β-hCG Negative Only)

• Order CT abdomen and pelvis with IV contrast (never pelvis alone) when:
  1. Ultrasound is nondiagnosive or equivocal. 1, 2
  2. High clinical suspicion exists for non-gynecologic pathology (appendicitis, bowel obstruction, abscess, urolithiasis). 1, 2
  3. Life-threatening conditions require rapid diagnosis. 2
  4. Severe pain persists or worsens despite negative initial workup. 1, 2
• CT demonstrates 89% sensitivity for urgent abdominal diagnoses and 74–95% sensitivity for adnexal torsion. 1, 8
• Never use CT as first-line for gynecologic causes; ultrasound provides equivalent or superior accuracy without radiation exposure. 1, 2

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Management by Diagnosis

Pelvic Inflammatory Disease (PID)

• Initiate empiric broad-spectrum antibiotics immediately when minimum criteria are met (uterine + adnexal + cervical motion tenderness), even before culture results. 7, 2
• Coverage must include N. gonorrhoeae, C. trachomatis, gram-negative facultative bacteria, anaerobes, and streptococci. 7
• Obtain cervical cultures for gonorrhea and chlamydia to guide partner treatment, but do not delay antibiotics. 2
• Treat sex partners empirically with regimens effective against C. trachomatis and N. gonorrhoeae; failure to do so places the patient at risk for reinfection and complications. 7
• Consider hospitalization if diagnosis is uncertain, surgical emergency cannot be excluded, pelvic abscess is suspected, patient is pregnant or adolescent, severe illness precludes outpatient management, or 72-hour follow-up cannot be arranged. 7

Endometriosis

• First-line medical therapy: NSAIDs for pain relief, followed by oral contraceptives or progestins (oral or depot medroxyprogesterone acetate). 7
• GnRH agonists for at least 3 months are equally effective as danazol (6 months) for pain relief; add-back therapy (estrogen-progestin or progestin alone) reduces bone mineral loss without reducing efficacy. 7
• Surgical therapy (laparoscopic excision or ablation) is associated with significant pain reduction in the first 6 months, but up to 44% of women experience symptom recurrence within 1 year. 7
• Empiric GnRH agonist therapy is appropriate for chronic pelvic pain even without surgical confirmation of endometriosis, provided initial evaluation excludes other causes. 7

Ovarian Torsion

• Urgent gynecologic consultation for immediate laparoscopic detorsion is the standard of care; ovarian preservation should be attempted even when the ovary appears necrotic, as intraoperative visual assessment is highly inaccurate (only 18–20% of necrotic-appearing ovaries are actually necrotic on pathology). 8

Vulvodynia and Vaginismus

• Topical analgesics (lidocaine ointment) for localized vulvar vestibulitis. 4
• Pelvic floor physical therapy for pelvic floor dysfunction and vaginismus. 4
• Vaginal dilators with progressive sizing for vaginismus. 4
• Modified vestibulectomy for refractory vulvar vestibulitis. 4
• OnabotulinumtoxinA injections for severe vaginismus. 4

Fibroids and Ovarian Cysts

• Symptomatic management is first-line for both conditions. 9
• Fibroids causing heavy menstrual bleeding or pelvic pressure can be managed medically (hormonal therapy) or surgically (myomectomy, hysterectomy) depending on symptoms and fertility desires. 9
• Ovarian cysts are generally managed expectantly unless complicated (torsion, rupture, hemorrhage). 9

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Critical Pitfalls to Avoid

• Never omit pregnancy testing; failure to obtain β-hCG can result in missed ectopic pregnancy and inappropriate radiation exposure. 1, 2
• Do not require multiple criteria before treating suspected PID; requiring two or more findings reduces sensitivity and misses cases that can cause permanent reproductive damage. 2
• Do not dismiss mild or atypical PID symptoms; many cases present with nonspecific symptoms like abnormal bleeding or dyspareunia. 2
• Do not use CT as first-line for gynecologic causes; ultrasound has equivalent or superior diagnostic accuracy without radiation. 1, 2
• Never order CT pelvis alone; it provides insufficient coverage for generalized abdominal pain and must be combined with abdominal imaging. 1, 2
• Normal arterial Doppler flow does not rule out ovarian torsion; torsion can be intermittent or partial, and venous flow abnormalities are more sensitive. 8