Signs and Symptoms of Endometriosis
Endometriosis presents with a characteristic triad of pelvic pain patterns—secondary dysmenorrhea (pain starting before menstruation), deep dyspareunia (painful intercourse worse during menses), and sacral backache with menses—though 90% of patients report some form of pelvic pain and up to 50% experience infertility. 1, 2, 3
Primary Clinical Manifestations
Pain Symptoms (Present in 90% of Cases)
Secondary dysmenorrhea is pain that commences before the onset of the menstrual cycle, distinguishing it from primary dysmenorrhea 1, 2
Deep dyspareunia (painful intercourse) that is characteristically exaggerated during menses 1, 2
Nonmenstrual pelvic pain can occur throughout the cycle, representing chronic pelvic pain independent of menstruation 3, 4
Dysuria (painful urination) may occur when endometriosis involves the urinary tract 5
Reproductive Dysfunction
Infertility affects approximately 26-50% of patients with endometriosis and may be the only presenting symptom in 20-30% of cases 5, 3, 6
Subfertility can occur without any accompanying pelvic pain 6
Important Clinical Correlations
Pain severity correlates with the depth of endometriosis lesions (lesions extending >5mm under the peritoneal surface), not with the type or extent of lesions seen at laparoscopy 1, 2, 5
Painful lesions typically involve peritoneal surfaces innervated by peripheral spinal nerves rather than the autonomic nervous system 1
The clinical presentation is highly variable, ranging from completely asymptomatic (2-22% of reproductive-age women) to debilitating symptoms that significantly impact daily activities 5, 4, 6
Less Common Presentations
Extrapelvic Manifestations
Inguinal region involvement can present as tender masses that fluctuate with the menstrual cycle, often initially confused with inguinal hernias 7
Abdominal wall scar endometriosis occurs after gynecologic procedures, presenting as tender masses fluctuating with menstruation, frequently misdiagnosed as incisional hernias 7
Endometriosis involving bowel, bladder, ureter, or vagina represents deep endometriosis and causes organ-specific symptoms 5
Associated Systemic Features
Chronic inflammation is a hallmark of the disease and contributes to varying symptom intensity over time 2
Cardiovascular risk factors including hypercholesterolemia and hypertension are associated with endometriosis 2
Patients have a 16-34% increased risk of stroke, making this a systemic disease rather than just a pelvic condition 2, 5
Key Clinical Pitfalls
Asymptomatic presentation occurs in a significant minority of women, with diagnosis rates of 2-22% in asymptomatic reproductive-age women undergoing laparoscopy for other reasons 6
Diagnostic delay averages 5-12 years after symptom onset, with most women consulting 3 or more clinicians before diagnosis 3
Normal physical examination and imaging do not exclude the diagnosis, as endometriosis can be present without detectable findings 3
The severity of symptoms does not correlate directly with the extent of disease visible at surgery 8