Symptoms of Endometriosis
Endometriosis presents with pelvic pain in 90% of cases, including dysmenorrhea, nonmenstrual pelvic pain, and dyspareunia, while 26% of affected women report infertility as their primary symptom. 1
Primary Pain Symptoms
The pain associated with endometriosis falls into three distinct categories that should guide clinical suspicion 2:
- Dysmenorrhea (secondary): Painful menstruation that typically worsens over time, distinguishing it from primary dysmenorrhea that begins at menarche 2, 3
- Deep dyspareunia: Pain with deep vaginal penetration during intercourse, reflecting involvement of pelvic structures 2, 1
- Sacral backache with menses: Lower back pain that occurs cyclically with menstruation, which may indicate bowel endometriosis involvement 2, 4
Additional Pelvic Pain Presentations
Beyond the classic triad, women experience 1, 3:
- Chronic nonmenstrual pelvic pain: Persistent pain lasting at least 6 months that occurs outside of menstruation 1
- Acyclic pelvic pain: Pain without clear relationship to the menstrual cycle, particularly in advanced disease 3
Gastrointestinal and Urinary Symptoms
When endometriosis involves the bowel or bladder, additional symptoms emerge 3:
- Period-related gastrointestinal symptoms: Diarrhea, constipation, painful bowel movements, or rectal bleeding that worsens during menstruation 3
- Period-related urinary symptoms: Painful urination, urgency, or hematuria coinciding with menses 3
- Bowel involvement symptoms: The rectosigmoid colon is affected in approximately 90% of bowel endometriosis cases, followed by sigmoid colon and cecum 4
Infertility as a Presenting Symptom
Infertility can be the sole presenting symptom in 20-30% of women with endometriosis, occurring without any pelvic pain. 5 This represents a critical diagnostic pitfall, as asymptomatic women undergoing infertility evaluation have endometriosis diagnosed in 2-22% of cases 5.
Important Clinical Caveats
The depth of endometriosis lesions correlates with pain severity, but there is little relationship between pain intensity and the type or extent of lesions seen at laparoscopy 2. This means severe symptoms can occur with minimal visible disease and vice versa, making symptom severity an unreliable predictor of disease extent.
Normal physical examination and imaging do not exclude the diagnosis of endometriosis. 1 The average diagnostic delay is 5-12 years after symptom onset, with most women consulting 3 or more clinicians before diagnosis 1.
Postmenopausal Considerations
While endometriosis is estrogen-dependent and typically regresses after menopause, rare cases occur in postmenopausal women without hormone therapy 6, 7. In these cases, symptoms likely result from scarring or disease reactivation 6.