Symptoms and Diagnosis of endometriosis


  Laparo     Delay    Mistakes


1: Symptoms+clinical exam+US ->Suspicion

Endometriosis -> pain

If pain

  • 50% of women have endometriosis
  • if very severe pain: more cystic and deep endometriosis


Endo and Infertility

  • +++ for cystic ovarian endometriosis
  • + for typical and deep endometriosis
  • no effect (?) of subtle or microscopical endometriosis
  • other forms
    • adenomyosis - pockets : decreases fertility variably

If infertility

  • 50% probability of typical lesions
  • all other causes remain possible

Conclusion 1

  • when pain or infertility : 50% of women have endometriosis
    • !!  Localization and radiation can suggest cystic ovarian or deep endometriosis
    • all women with pain or in fertility are suspected to have endometriosis
  • Other symptoms, often quoted on web-sites and lay press, have a weak association .  eg abnormal or heavy bleeding, bowel symptoms or bloating.


Which pain?

  • Generally dysmenorrhea
  • sometimes chronic pain
  • deep dyspareunia in deep endometriosis or cystic ovarian endometriosis 

Where pain?

  • hypogastric pain generally radiating to the back ;
  • radiation in the anterior part of the upper leg suggests cystic ovarian endometriosis
  • perineal pain is pathognomonic for deep endometriosis
  • dyschezia, i.e. bowel cramps and pain during menstruation, or menstrual blood loss on the stools. Also, cyclic diarrhea and/or constipation can be suggestive.
  • Urinary symptoms. Frequency, urgency, bladder pain, and occasionally bloody urine may occur when endometriosis has involved the bladder.
  • Endometriosis invading the ureter causing obstruction cause ureter pain.

2 : Clinical exam - ultrasound- investigations


Clinical exam: diagnosis of endo in less than 50%clinical diagnosis of deep endometriosis

  • not useful for Subtle  and  typical Endometriosis (occasionally felt as shots)
  • Cystic ovarian Endometriosis.  Only larger cysts are diagnosed clinically.
  • Deep Endometriosis:  only half of the large  lesions. Important is the importance of a clinical exam during menstruation

A negative clinical exam cannot exclude endometriosis


  • is the method of choice to diagnose cystic ovarian endometriosis
  • cannot diagnose superficial endometriosis
  • the predictive value for deep endometriosis is only 90% if experience and a larger nodule, but limited for smaller lesions
  • For a detailed discussion on the pitfalls of ultrasound read 2021_pk_pitfalls-US

Conclusion 2

  • an endometrioma is diagnosed in US but malignity cannot be excluded.
  • A cystic corpus luteum causes false positives.
  • Ultrasound imaging needs to be interpreted in close collaboration with the surgeon.
  • Malignancy?  some 3% of the endometrioma’s are malignant in women after menopause,

Other exams

adenomyosis of the junctional zone

These exams are only useful as a preparation for surgery but limited for diagnosis.

  • Cat scan and colonoscopy can detect very large deep endometriosis.
  • MRI is overused especially for pain in general.
    • Not useful for superficial endometriosis.
    • No added value for cystic ovarian endometriosis.
    • For deep endometriosis: similar to ultrasound without added value
    • MRI is useful for diagnosing adenomyosis, as a thickened junctional zone, or as a focal adenomyosis

3. The decision to do a laparoscopy

Decision tree 

  • The first decision, is whether a laparoscopy should be planned
    • This decision is clear when a deep nodule or a large cystic ovarian endometriosis are diagnosed. 
    • The decision is clinical in all other women with pain and/or infertility.  Ultrasound imaging  alone is not an indication (although often misused).
  • The second decision, when a laparoscopy is planned, is which additional exams should be done and how surgery should be planned
    • If deep endometriosis is not suspected a bowel preparation is not necessary and surgery can be done as day care.
    • If deep endometriosis is suspected, additional exams as contrast enema and IVP, and a bowel preparation before surgery are mandatory. IVP diagnoses hydronefrosis i.e. whether ureter stents are necessary. A contrast enema diagnoses bowel occlusion. The degree and length of occlusion predict the difficulty of surgery, and thus for the informed consent.
  • Laparoscopy remains the gold standard for diagnosis.
    • The usefulness of imaging to predict surgical difficulty is limited.
    • Imaging alone is rarely an indication for a bowel resection
    • Too often imaging  is used as a alibi to do (unnecessary) bowel resections

Why is the delay in diagnosis long.?

  • the gynecologist needs experience to suspect Endometriosis : we only recognize what we know.
  • the non-surgeons exaggerate medical treatment to avoid surgery, 
  • endometriosis surgery is difficult and pelvic surgeons are rare. Less experienced surgeons  often prefer to give medical therapy before referring the patient.
  • The erroneous belief that all endometriosis can be diagnosed by anything else than by a laparoscopy
  • the difficulty of surgery is difficult to predict. Therefore I introduced Oxford that the ex-fellows could perform a diagnostic laparoscopy and judge if they could do the surgery;  if not, they refer.


  • Medical treatment for long periods without a diagnosis .
  • medical treatment without follow-up
  • Superficial coagulation of typical lesions  since often incomplete .
  • Drainage of cystic ovarian endometriosis 
  • Miss-diagnosis of a cystic corpus luteum
  • Destruction of the ovary,  by lack of experience.
  • Missing Deep endometriosis. or Incomplete excision of deep endometriosis by lack of experience and by fear of complications. 
  • Unnecessary rectum resection for recto-vaginal endometriosis
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