Symptoms

Introduction
Definition
Incidence
Cause
Symptoms
Intestinal Endometriosis
Infertility
Diagnosis
Treatment
Adenomyosis
Are you too young to have
a laparoscopy?
Endometriosis and cancer
Treatment summary
Endometriosis and heredity

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Endometriosis is a variable disease and it has been well known for many years that there is no relationship between the severity of its symptoms and the actual extent of the Endometriosis. Women with minimal Endometriosis may have incapacitating pelvic pain whereas women with severe Endometriosis may present with infertility as the only indication as to its presence. Again, abnormalities in immune function undoubtedly explain some of this discrepancy.

For those women who do have symptoms, 3 major pain patterns are recognized. Women with Endometriosis commonly have significant pain with their periods. It is not the severity of the pain per se that provides the clue to Endometriosis but rather the pattern. Women with Endometriosis may show the same pattern of their dysmenorrhea (painful menstruation) as do women with other problems, but when certain patterns are present, they are very distinctive and very strongly suggestive of Endometriosis.

Women with Endometriosis commonly indicate that their dysmenorrhea begins as long as 2 weeks before the onset of their menstrual period (i.e., at the time of ovulation). Many women with Endometriosis have significant mid-cycle pain. Women with Endometriosis commonly indicate that their dysmenorrhea is progressively worsening. If a woman did not have dysmenorrhea as a teenager but developed it in her twenties or later, that is another important clue to Endometriosis.

In addition to the pain beginning more than a day or so before the flow, women with Endometriosis frequently report that the pain, instead of disappearing after the first day or two of the flow, will persist throughout the entire length of the period and will often persist after the flow has ended. These patterns of pain are, in my experience, seen only in women with Endometriosis.

Another common symptom of Endometriosis is deep pain with intercourse (dyspareunia). Pain on intercourse associated with deep penetration is, without exception, a symptom of organic pelvic disease. Women with Endometriosis note that intercourse is often more painful when they are premenstrual. They also often complain that not only is intercourse itself painful but that the discomfort may persist after intercourse.

Many women have said to me they were told that intercourse was painful because their uterus was tipped backward. A tipped back uterus is a normal anatomical variation and almost never, if ever, produces symptoms. Women who have tipped a back uterus with significant pelvic symptoms have some pelvic disease as the cause of their symptoms. Most women with a tipped back uterus don't even know it unless told by a physician.

The third major symptom of Endometriosis is deep pelvic tenderness, particularly on rectal examination. Even though I am well aware that people do not like rectal examinations, they are nonetheless an essential and integral part of the pelvic examination.

The deep pelvis behind the uterus (called the "cul-de-sac") is the most common site for Endometriosis, simply because gravity pulls the endometrial cells down where they implant and grow. In my experience, tenderness in the deep central pelvis on rectal examination is almost as diagnostic of Endometriosis as a laparoscopy.

Keep in mind that the symptoms I have just described are only general guidelines. Women with Endometriosis show amazing variability as to the amount, severity and pattern of their symptoms.

The only other major cause of chronic pelvic pain that could be confused with Endometriosis is the presence of significant pelvic adhesions and scar tissue from either a previous infection or pervious pelvic surgery. In some instances, it is impossible on the basis of the woman's symptoms and pelvic exam to make a distinction.