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Clinical features

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

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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