Endometriosis is having extrauterine endometrial tissue that causes chronic inflammatory response.

The patient experiences chronic pelvic pain, pain during intercourse and/or menstruation and infertility.

Diagnosis is attained by pathologic examination of the tissue obtained from laparoscopy or laparotomy.

Goals of treatment are decreasing pain, enhancing fertility, and preventing progression or recurrence. 



  • Should include:
    • Age (reproductive year, most commonly at 25-29 years old)
    • In utero exposure to environmental toxins like diethylstilbestrol which increases the incidence of endometriosis
    • Family history of endometriosis (7x higher risk than with no family history)

Physical Examination

  • Ideally done during early menses because endometrial implants are likely to be largest and deep infiltrating, hence more easily detectable
  • 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 pouch of Douglas, and/or lesions are directly seen in the vagina or cervix
  • Note that there may be no abnormal findings on physical exam
  • For patients who are not sexually active, a rectal-abdominal exam may be better tolerated than a vaginal-abdominal exam
  • 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
Other Frequent Findings:
  • Pain with uterine movement or pelvic tenderness
  • Tender, enlarged adnexal masses
  • Fixation of adnexa or uterus in a retroverted position

Laboratory Tests

  • Urinalysis and urine culture to identify pain originating in the urinary tract (eg cystitis, stones)
  • Pregnancy test and tests for sexually transmitted infection (STI) like gonorrhea, chlamydia, when appropriate
Miscellaneous Test
Serum CA-125 
  • Women with endometriosis may have high serum CA-125 concentration
    • No value as diagnostic tool in endometriosis, though it may be used to assess the presence of an undiagnosed adnexal mass
    • Also elevated in ovarian epithelial neoplasia, myoma, adenomyosis, acute pelvic inflammatory disease (PID), ovarian cyst, pregnancy


Transvaginal Sonography (TVS)
  • Considered the 1st-line imaging tool to examine suspected endometriosis
  • Should be performed to determine whether a pelvic mass or structural anomaly is present
  • Useful in diagnosing or excluding rectal endometriosis
  • May identify an ovarian endometrioma and help identify other structural causes of pelvic pain, such as ovarian cysts, torsion, tumors, genital tract anomalies and appendicitis
    • Distinguishes endometrioma from other ovarian cysts with 83% sensitivity and 89% specificity
    • Ovarian endometrioma may be diagnosed in premenopausal women with findings of ground glass echogenicity and 1-4 compartments and absence of papillary structures with blood flow
Magnetic Resonance Imaging (MRI)
  • May be helpful in some cases to better define an abnormality suspected by sonography
    • Detects ovarian endometrial cysts with 90% sensitivity and 98% specificity
  • Provides exact location of deep retroperitoneal lesion
  • May be used as part of pre-op workup, but should not be used as 1st-line
Other Imaging Studies
  • Cystoscopy, colonoscopy and rectal ultrasonography may be required if deep endometriosis is suspected

Surgical Tests

  • Gold standard for diagnosis, unless lesions are visible in the vagina
    • May also be used for therapeutic purposes
    • Should not be done during or within 3 months of hormonal treatment to avoid under-diagnosis
  • Biopsy and histopathologic study of at least one lesion is ideal
    • 3 cardinal features (ie ectopic endometrial glands, ectopic endometrial stroma, and hemorrhage into adjacent tissue) should be present
    • In adolescents, features of endometriosis may be atypical (ie clear vesicles and red lesions)
  • A negative laparoscopy does not exclude the diagnosis of endometriosis
  • Depending on the severity of the disease found, it is best to remove the endometriotic lesion at the same time
  • Differential diagnoses (eg endosalpingiosis, mesothelial hyperplasia, hemosiderin deposition, hemangiomas, adrenal rests, inflammatory changes, splenosis and reactions to oil-based radiographic dyes) can be excluded by biopsy
Laparoscopic Classifications (based on location, extent and severity of lesions)
  • Revised American Society for Reproductive Medicine (rASRM) Score [formerly the Revised American Fertility Society (rAFS) Score] 
    • Noted aspects include bilaterality, depth of invasion, size, involvement of the ovary and cul-de sac, and density of adhesions
    • Scores are as follows: 1-5 minimal disease (stage I), 6-15 mild disease (stage II), 16-40 moderate disease (stage III), >40 severe disease (stage IV) 
    • Does not take into account the retroperitoneal structures and deep infiltrating endometriosis 
  • Enzian Staging System
    • Presence of deep infiltrating endometriosis is taken into account  
    • Supplements the rASRM score with a description of deep infiltrating endometriosis, retroperitoneal structures and other organ involvement
  • May be considered in suspected endometriosis lesions and endometriomas to help confirm the diagnosis and exclude possible malignancy
    • In patients with endometriosis, prevalence of ovarian cancer is <1%
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