Which symptom would best raise suspicion for endometriosis in a patient with pelvic pain?

• A. PID history
• B. Dysmenorrhea unresponsive to NSAIDs
• C. Atypical Pap smear
• D. Abdominal bloating before menses

Answer: (B)

Endometriosis should be suspected when menstrual cramps are unusually severe and do not improve with standard NSAID therapy. Pain from endometriosis is driven by ectopic endometrial tissue that responds to hormones each cycle, leading to inflammation and pain that often persists or recurs despite NSAIDs. That contrast with primary dysmenorrhea, where cramps are typically self-limited and more responsive to NSAIDs, makes nonresponsive dysmenorrhea a stronger clue for an underlying condition like endometriosis.

Considering the other options, a history of pelvic inflammatory disease points more toward an infectious or inflammatory process rather than a gynecologic pain syndrome like endometriosis. An atypical Pap smear signals cervical pathology, not endometriosis. Abdominal bloating before menses is common and nonspecific, seen with premenstrual symptoms or other conditions, and does not point as strongly to endometriosis as nonresponsive dysmenorrhea does.

So the symptom that best raises suspicion for endometriosis in a patient with pelvic pain is dysmenorrhea that does not respond to NSAIDs.