fore menses begin, with the worst pain experienced on
the first day of flow; the pain disappears completely by
the third day of flow. Ms. S is gravida 0; last normal men-
strual period (LMP) began 6 days ago at her office visit.
Her physical exam was unremarkable with the exception
of a dry vaginal vault. She had been treated conserva-
tively by her primary care physician with OCs and non-
steroidal anti-inflammatory drugs (NSAIDs) for her dys-
menorrhea with no relief. Her surgical history included
abdominal surgery as an infant to enclose the bladder
inside the pelvic cavity with no subsequent problems.
She also reported painful intercourse (dyspareunia) and
vaginal dryness with penile thrusting for the past 4
months about 1 week before onset of her period. Patient