Symptoms of Endometriosis
Endometriosis presents primarily with pelvic pain, which typically manifests as dysmenorrhea (painful periods), deep dyspareunia (pain during intercourse), and nonmenstrual pelvic pain, affecting approximately 90% of patients with this condition. 1
Common Symptoms
Endometriosis symptoms vary in presentation and severity, ranging from asymptomatic to debilitating pain. The most frequent symptoms include:
Pelvic pain, which falls into three main categories 2:
- Secondary dysmenorrhea (pain beginning before menstruation)
- Deep dyspareunia (painful intercourse, often worse during menses)
- Sacral backache associated with menstruation
Menstrual abnormalities:
- Severe menstrual cramps
- Heavy menstrual bleeding (menorrhagia)
- Irregular periods
Infertility affects approximately 26% of women with endometriosis 1
Other pain symptoms:
- Dyschezia (painful bowel movements, especially during menstruation)
- Dysuria (painful urination)
Diagnostic Challenges
The diagnosis of endometriosis is often delayed, taking 5-12 years from symptom onset, with most women consulting 3 or more clinicians before receiving a diagnosis 1. This delay occurs because:
- Symptoms can mimic other conditions
- Physical examination may be normal
- The definitive diagnosis requires surgical visualization of lesions
Treatment Options
First-Line Treatment
For women not seeking immediate pregnancy, hormonal medications are the first-line treatment 1:
- Combined oral contraceptives
- Progestin-only options (pills, injections, or IUDs)
These treatments have shown clinically significant pain reduction compared to placebo, with mean differences ranging between 13.15 and 17.6 points on a 0-100 visual analog scale 1.
Second-Line Treatment
When first-line treatments fail or are contraindicated:
- GnRH agonists (with add-back therapy to prevent bone mineral loss)
- GnRH antagonists
Third-Line Treatment
- Aromatase inhibitors
Surgical Options
Surgical intervention should be considered when:
- Hormonal therapies are ineffective or contraindicated
- Definitive diagnosis is needed
- Fertility is the primary concern
Surgical approaches include:
- Laparoscopic removal of endometriotic lesions
- Hysterectomy with removal of lesions in severe cases unresponsive to other treatments
Important Considerations
- Pain severity does not necessarily correlate with the extent of visible lesions 2
- Depth of lesions correlates better with pain severity than appearance 2
- No medical therapy completely eradicates endometriosis lesions 2
- Approximately 11-19% of patients experience no pain reduction with hormonal medications 1
- 25-34% experience recurrent pain within 12 months of stopping hormonal treatment 1
- Even after hysterectomy, about 25% of patients experience recurrent pelvic pain 1
Early recognition of symptoms and prompt treatment are essential to improve quality of life and prevent progression of the disease. Patients with suspected endometriosis should be referred to a gynecologist experienced in managing this condition.