Signs and Symptoms of Endometriosis
The cardinal signs of endometriosis are pelvic pain (present in 90% of patients) and infertility (affecting 26-50% of patients), with pain manifesting as dysmenorrhea, non-menstrual pelvic pain, dyspareunia, dysuria, and dyschezia. 1, 2
Primary Clinical Manifestations
Pain Symptoms
- Pelvic pain is the dominant presenting symptom, occurring in approximately 90% of patients with endometriosis 2
- Dysmenorrhea (painful menstruation) is one of the most frequently reported symptoms 3
- Deep dyspareunia (painful intercourse) is a characteristic symptom 3
- Dysuria (painful urination) occurs when lesions affect the urinary tract 1, 3
- Dyschezia (painful bowel movements) is common, particularly with deep endometriosis involving the bowel 3
- Non-menstrual pelvic pain can occur throughout the cycle 2
Reproductive Manifestations
- Infertility affects 26-50% of patients with endometriosis 1, 2
- Infertility may be the presenting complaint in women who do not experience significant pain symptoms 4, 5
Systemic and Associated Symptoms
- Fatigue is a common associated symptom 5
- Multisite pain beyond the pelvis can develop 5
- The clinical presentation is highly variable, ranging from completely asymptomatic to severe symptoms that significantly impact daily activities 1
Physical Examination Findings
Key Examination Signs
- Physical examination may reveal tenderness on pelvic examination, though normal physical examination does not exclude the diagnosis 2
- Deep endometriosis may be palpable on rectovaginal examination, particularly when involving the uterosacral ligaments, rectovaginal septum, or posterior vaginal fornix 6
Important Clinical Considerations
Diagnostic Challenges
- Diagnostic delay averages 5-12 years from symptom onset to diagnosis, with most women consulting 3 or more clinicians before diagnosis 2
- The diverse symptomatology and overlap with other conditions contribute to this delay 5, 7
- Endometriosis should be approached as a chronic, systemic, inflammatory disease rather than focusing solely on surgical findings 7
Disease Characteristics
- Endometriosis is estrogen-dependent and manifests during reproductive years 3
- The condition is characterized by chronic inflammation affecting an estimated 176 million women worldwide 1
- Symptoms typically improve during pregnancy and after menopause due to hormonal changes 3
Clinical Pitfalls to Avoid
- Do not delay clinical diagnosis waiting for surgical confirmation - a suspected clinical diagnosis can be made based on symptoms, supported by physical examination and imaging 2, 7
- Do not dismiss normal imaging or examination findings - these do not exclude endometriosis 2
- Consider gastrointestinal and urinary symptoms as potential manifestations of endometriosis rather than separate conditions 8
- Recognize that approximately 10% of patients may be asymptomatic despite having endometriosis 1