A 33-year-old nulligravid woman presents with a complaint of insertional dyspareunia. She has been partnered with the same man for three years and had no issues with coitus until about one year ago. Since that time, she has experienced increasingly severe pain with any attempt at vaginal insertion. She describes the pain as sharp and tearing, occurring when her partner enters her. Because of the pain, she has also experienced diminished arousal and a lack of sexual desire. She denies any vulvar pain in other situations but has a similar sensation with placement of a tampon or sex toy. A trial of topical estrogen worsened her symptoms. Application of lidocaine jelly to the area resulted in improvement of symptoms temporarily, but intercourse without it was persistently painful. Her gynecologic history is notable only for a history of recurrent candida vaginitis, though she has no symptoms currently. She uses a combined oral contraceptive for birth control. She has no significant medical history and has never had surgery. She is a non-smoker and uses alcohol occasionally.