Clinical evaluation

A. Endometriosis should be considered in any woman of reproductive age who has pelvic pain. The most common symptoms are dysmenorrhea, dyspareunia, and low back pain that worsens during menses. Rectal pain and painful defecation may also occur. Other causes of secondary dysmenorrhea and chronic pelvic pain (eg, upper genital tract infections, adenomyosis, adhesions) may produce similar symptoms.

Differential Diagnosis of Endometriosis

Generalized pelvic pain

Dyspareunia

Pelvic inflammatory

Musculoskeletal causes

disease

(pelvic relaxation, levator

Endometritis

spasm)

Pelvic adhesions

Gastrointestinal tract (con-

Neoplasms, benign or

stipation, irritable bowel

malignant

syndrome)

Ovarian torsion

Urinary tract (urethral syn-

Sexual or physical

drome, interstitial cystitis)

abuse

Infection

Nongynecologic

Pelvic vascular congestion

causes

Diminished lubrication or

Dysmenorrhea

vaginal expansion because

Primary

of insufficient arousal

Secondary

Infertility

(adenomyosis,

Male factor

myomas, infection,

Tubal disease (infection)

cervical stenosis)

Anovulation

Cervical factors (mucus,

sperm antibodies, stenosis)

Luteal phase deficiency

B. Infertility may be the presenting complaint for endometriosis. Infertile patients often have no painful symptoms.

C. Physical examination. The physician should palpate for a fixed, retroverted uterus, adnexal and uterine tenderness, pelvic masses or nodularity along the uterosacral ligaments. A rectovaginal examination should identify uterosacral, cul-de-sac or septal nodules. Most women with endometriosis have normal pelvic findings.

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