Symptoms may be absent (in about one-fifth of patients) (1).
Suspect endometriosis in patients presenting with any of the following (2):
- secondary dysmenorrhoea -
- commonest presenting symptom seen in around 85% of patients
- usually worsening from the late twenties onwards
- rarely, it may occur at menarche in endometriosis associated with obstructive genital anomalies
- deep dyspareunia -
- mainly with lesions in the pouch of Douglas, uterosacral ligaments, and posterior vaginal fornix
- pain continues for a variable time after intercourse (1)
- chronic pelvic pain
- variable in severity and location
- causes include adhesions, large ovarian cysts, peritoneal inflammation (from active endometriosis) and involvement of the bowel or bladder (1)
- pain at the time of ovulation
- infertility
- 30-40% of couples are infertile if the female has endometriosis, compared to about 10% normally
- pregnancy rates are the same with and without treatment if there is minimal disease, ie endometriosis is not the 'cause' of infertility if the patient only has minimal disease.
- cyclical or perimenstrual symptoms, affecting the bowel or bladder, with or without abnormal bleeding or pain
- dyschezia, hematochezia - in bowel involvement
- dysurea, haematurea - in bladder involvement
- menstrual disorders
- premenstrual or postmenstrual spotting; menorrhagia (adenomyosis)
- chronic fatigue (1)
Signs may be absent or may include:
- tender nodules along the uterosacral ligaments, or in the pouch of Douglas
- a fixed, retroverted uterus on bimanual examination
- enlarged ovaries
- visible lesions in the vagina or on the cervix (1)
- tender, fixed adnexia
- blood filled, chocolate cysts may be seen on laparoscopy
NICE have produced a "checklist" of clinical features that may alert a clinician of possible endometriosis (4):
- Endometriosis symptoms and signs
- a clinician should suspect endometriosis in women (including young women aged 17 and under) presenting with 1 or more of the following symptoms or signs:
- chronic pelvic pain
- period-related pain (dysmenorrhoea) affecting daily activities and quality of life
- deep pain during or after sexual intercourse
- period-related or cyclical gastrointestinal symptoms, in particular, painful bowel movements
- period-related or cyclical urinary symptoms, in particular, blood in the urine or pain passing urine
- infertility in association with 1 or more of the above
- an abdominal and pelvic examination should be offered to women with suspected endometriosis to identify abdominal masses and pelvic signs
- such as reduced organ mobility and enlargement,
- tender nodularity in the posterior vaginal fornix,
- and visible vaginal endometriotic lesions
- if a pelvic examination is not appropriate, offer an abdominal examination to exclude abdominal masses.
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