History and exam
Key diagnostic factors
common
dysmenorrhea
Primary dysmenorrhea is extremely common in young girls and may be difficult to distinguish from dysmenorrhea caused by endometriosis.[1]
Suspect endometriosis if dysmenorrhea progresses and becomes acyclic.
chronic or cyclic pelvic pain
The cause of chronic pain is often multifactorial, but endometriosis must be considered. Pain characterized as progressively worsening and continuous, however, is most characteristic for women with endometriosis.
dyspareunia
Approximately 30% of women with endometriosis report dyspareunia.[5] Pain during sexual intercourse, particularly with deep penetration, may be caused by distortion of pelvic anatomy and rectovaginal involvement.
subfertility
Endometriosis is present in up to 40% of women presenting with unexplained infertility.[33] These women may otherwise be asymptomatic.
Due to scarring or prostaglandin overproduction that can interfere with fertilization or implantation.
uterosacral ligament nodularity
Palpable by rectovaginal examination.
A "guitar string" texture associated with tenderness is typical when these peritoneal structures are involved. Sensitivity as high as 85%.[51]
pelvic mass
Ovarian endometriomas (chocolate cysts) may be felt on pelvic exam. Although classified as stage III to IV endometriosis, these women may be asymptomatic.
fixed, retroverted uterus
Late finding suggestive of peritoneal fibrosis and pelvic adhesions. May be associated with a "frozen pelvis" (posterior cul-de-sac is filled with immobile pelvic organs). Commonly manifests as uterine tenderness.
depression
Present in 30% to 85% of women with endometriosis.[34] Women with endometriosis are more likely to have depression, compared with healthy controls, but not compared with people with chronic pelvic pain from other causes.[35] Therefore, women presenting with endometriosis, especially if associated with chronic pain, should be assessed for signs and symptoms of depression.
anxiety
Women with endometriosis are more likely to have anxiety, compared with healthy controls, but not compared with people with chronic pelvic pain from other causes.[35]
unable to attend work or school due to dysmenorrhea
Absenteeism from work or school is predictive of a diagnosis of endometriosis.[37]
Other diagnostic factors
uncommon
Risk factors
strong
reproductive age group
Endometriosis typically affects women of reproductive age, but a wide spectrum of age at diagnosis exists.[4]
positive family history
nulliparity
Nulliparous women are more likely than parous women to be diagnosed with endometriosis.[31]
mullerian anomalies
Differentiation of coelomic epithelium into endometrial glands is a possible mechanism. Endometriosis documented in premenarcheal girls is thought to arise from mullerian rests, cells of paramesonephric origin already in the pelvis, which are stimulated by estrogen production once maturation of the hypothalamic-pituitary-ovarian axis occurs.[22] Deep peritoneal disease with no obvious superficial implants is suggestive of this process, and may explain advanced stages noted in particularly young cohorts.
weak
low body mass index (BMI)
The prevalence is thought to be higher in those with lower BMIs.[11]
autoimmune disease
An increased prevalence of autoimmune diseases has been noted in women with surgically confirmed endometriosis.[27]
late first sexual encounter
Has been weakly associated with endometriosis.[11]
smoking
Has been weakly associated with endometriosis.[11]
previous cesarean section
Has been weakly associated with general pelvic endometriosis.[32] Further studies are needed to confirm the association.
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