Endometriosis Initial Assessment

Clinical Presentation

The main clinical features of endometriosis include chronic pelvic pain (found in 70-82% of patients, dyspareunia (suggests deep posterior infiltration), and infertility (21% prevalence rate). Other symptoms may include severe dysmenorrhea, pain on ovulation, noncyclical pelvic pain, cyclical bowel or bladder symptoms with or without abnormal bleeding or pain, dyschezia, dysuria, chronic fatigue, or abdominal or lower back discomfort.

In adolescents, endometriosis is the most common cause of secondary dysmenorrhea. Although it is vital to consider the patient’s complaints affecting physical, mental, and social well-being, it should be noted that patients with endometriosis may be completely asymptomatic (with a 2-22% prevalence rate).

History

History should include the patient’s age (reproductive year, most commonly at 25-29 years old), in utero exposure to environmental toxins like Diethylstilbestrol which increases the incidence of endometriosis, and family history of endometriosis (7 times higher risk than with no family history). 

Physical Examination

Physical examination is ideally done during early menses when endometrial implants are likely to be largest and deep infiltrating, hence more easily detectable.

It is important to perform abdominal inspection and palpation, a rectovaginal examination, and assess the uterus’ mobility, position, and size. Diagnosis is more definite if deeply infiltrative nodules are found on the uterosacral ligaments or in the pouch of Douglas, and/or lesions are directly seen in the vagina or cervix. Note that there may be no abnormal findings on physical examination. 

A cotton swab can be inserted into the vagina to document patency and exclude complete or partially obstructive anomalies such as a transverse vaginal septum, imperforate or microperforate hymen, or an obstructed hemivagina. 

For patients who are not sexually active, a rectal-abdominal examination may be better tolerated than a vaginal-abdominal examination.

Other frequent findings during a physical examination include pain with uterine movement or pelvic tenderness, tender and enlarged adnexal masses, fixation of adnexa or uterus in a retroverted position, uterosacral ligament tenderness, and rectovaginal septum induration.