Symptoms and Diagnosis

Essentials you should know


  Laparo     Delay    Mistakes

Endometriosis can be suspected

  • In 50% of women with pain or infertility
  • in 80% of women with severe pelvic pain
  • in 20% of women with heavy bleeding
  • and in some women, because of clinical exams or imaging

Endometriosis can cause pain

Endo can cause Infertility

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

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 websites and lay press, are weakly associated .  eg abnormal or heavy bleeding, bowel symptoms or bloating.


Endometriosis associated  pain?

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

Where pain: see images 

Generally 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 together with dyschezia or menstrual blood loss on the stools or cyclic diarrhea and/or constipation .
  • Urinary symptoms. Frequency, urgency, bladder pain, and occasionally bloody urine may occur when endometriosis has involved the bladder.

How useful are Clinical exam and imaging as ultrasound


Clinical examclinical diagnosis of deep endometriosis

  • not useful for superficial Endometriosis (occasionally felt as shots)
  • Cystic ovarian Endometriosis.  Only larger cysts are diagnosed clinically.
  • Deep Endometriosis:  less than half of the large lesions. Important is importance of a clinical exam during menstruation
  • A negative clinical exam cannot exclude endometriosis

Conclusion 2

  • an endometrioma is diagnosed by 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,

adenomyosis of the junctional zone
Cat scan and colonoscopy

  • only indicated for very large deep endometriosis nodules.


  • 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


The decision to do a laparoscopy is a difficult clinical decision

Why is the delay in diagnosis long.?

  • Too little experience to suspect Endometriosis: we only recognize what we know.
  • The non-surgeons exaggerate the use of medical treatment  
  • endometriosis surgery is difficult and pelvic surgeons are rare.
  • The erroneous belief that all endometriosis can be diagnosed by imaging
  • the difficulty of surgery is difficult to predict. Therefore I introduced Oxford, where the ex-fellows could perform a diagnostic laparoscopy and judge if they could do the surgery;  if not, they refer.


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