Diagnosing Endometriosis: Symptoms and Examination

Experiencing pain before or during menstruation can arise from various sources, with endometriosis being a prevalent culprit. Despite its common occurrence, this chronic but benign condition remains relatively obscure. Estimates suggest that approximately 10 to 15% of women of reproductive age grapple with endometriosis, impacting about 2 million women in Germany alone.

More than three-quarters of chronic lower abdominal pain cases can be attributed to this benign growth. For affected women, this often translates to a substantial decline in their quality of life. Moreover, roughly half of women facing challenges with fertility have endometriosis as a diagnosis.

Considering that cycle-related discomfort and pain are often considered normal, the significance of comprehensive education and enhanced diagnostic avenues cannot be overstated.

Understanding Endometriosis

Endometriosis involves the growth of tissue resembling the uterine lining outside the uterus, leading to discomfort.

These tissue cells mimic the behavior of endometrium within the uterus, undergoing monthly growth and bleeding during menstruation.

This process can lead to inflammation, cysts, and in the affected area or organ, occasionally resulting in severe pain. Additionally, endometriosis can contribute to reduced fertility or even infertility.

Where Endometriosis Occurs

Primarily, endometriosis arises on the peritoneum within the lesser pelvis, the Douglas space, and the outer uterine wall. However, endometriosis lesions are also commonly found on the ovaries, fallopian tubes, cervix, and vagina.

Endometriosis can extend into the abdomen, manifesting anywhere on the peritoneum, near the pelvic walls’ ureters, intestines, or bladder.

In such cases, endometriosis can form shallow foci or infiltrate tissues deeply, causing discomfort.

Notable variants of endometriosis include adenomyosis (endometriosis within the uterine wall), chocolate cysts (endometriosis cysts in the ovaries with bleeding), and endometriosis within cesarean section scars.

Instances of endometriosis lesions outside the abdomen, such as in the lungs or brain, are extremely rare.

When Does Endometriosis Occur?

Endometriosis typically manifests during the childbearing years, generally between ages 13 and 49. In some instances, endometriosis might arise before a woman’s first period or after menopause.

Causes of Endometriosis

The precise causes of endometriosis are not yet fully understood. Diverse theories propose that endometriosis lesions could involve endometrial cells that enter the abdominal cavity through the fallopian tubes or other cell types, like stem cells that transform into endometrial cells. Immunological factors are also considered.

Contemporary medical thought suggests that multiple factors contribute to its onset.

Research also indicates a higher occurrence of these benign uterine lining growths among families. However, direct hereditary transmission has not been established.

Potential Symptoms

Endometriosis might be symptomatic or asymptomatic. Common indicators include varying degrees of pain, often chronic, and difficulty conceiving. Pain can radiate and is frequently reported shortly before and during menstruation. Some individuals experience pain during sexual intercourse or at times unrelated to their menstrual cycle.

The distinct and sometimes dismissed (“just menstrual pain”) symptoms, unfortunately, contribute to delayed diagnosis, extending for several years.

Key symptoms of endometriosis encompass:

It is important to note that many of these symptoms do not consclusiveluy point to endometriosis, and not every symptom occurs in every affected woman. Consequently, diagnosis can be challenging, and endometriosis might remain undetected without thorough investigation.

Furthermore, symptom severity does not necessarily correlate with the extent of the endometriosis growth. For instance, even small lesions can cause severe symptoms, while extensive endometriosis might remain asymptomatic.

With time, these growths can increase in size, infiltrate tissues such as the intestines, and potentially lead to cyst formation.

Different Forms of Endometriosis

Endometriosis has been categorized into four stages (rASRM classification) to facilitate assessment, enabling the classification of size and extent.

Stage 1
– Minimal Endometriosis
Individual growths are no larger than 5 mm.

Stage 2
– Mild Endometriosis
Growths on the ovaries and fallopian tubes exceed 5 mm in size, often accompanied by bleeding.

Stage 3
– Moderate Endometriosis
Endometriosis lesions extend into the pelvic region, often accompanied by cysts and hemorrhaging.

Stage 4
– Severe Endometriosis
Tissue sections and growths can emerge in the intestines, bladder, and even areas like the liver or lungs. Additionally, monthly bleeding can occur.

However, this classification does not precisely reflect the affected women’s symptoms, as symptom severity can differ substantially even with similar degrees of endometriosis.

Diagnosing Endometriosis 

Patient symptoms widely vary in nature and intensity, which can complicate prompt diagnosis. Ignorance about the condition further delays diagnosing endometriosis.

Typically, anamnesis (medical history) followed by a speculum and palpation examination is conducted. Subsequently, a vaginal ultrasound examination might provide additional insights. When suspicion of endometriosis is confirmed, laparoscopy is usually performed. This surgical procedure aids in identifying endometriosis lesions, enabling the removal of small tissue sections if necessary.

MRI might prove helpful in some cases, especially if endometriosis localizations exist outside the abdominal cavity (e.g., on nerves, in the lungs, or brain). An MRI for suspected endometriosis should be scheduled during the menstrual period.

Particularly in cases of superficial endometriosis, palpation, and ultrasound examinations might yield inconclusive results. Thus, diagnosis for this common form of endometriosis often relies on medical history, symptoms, and surgical procedures.

Diagnostic Process:


A comprehensive discussion between doctor and patient is a significant part of the diagnosis. Documenting all symptoms and complaints, including pain, sexual intercourse issues, fertility concerns, and menstrual irregularities, is crucial. Pain intensity and the extent of quality-of-life impairment are also pivotal indicators, given patients often have an extensive medical history.

Speculum and Palpation Examination

The vaginal examination helps identify tissue changes, and scarring, and assess bleeding. A speculum allows the doctor to examine the vaginal walls and the cervix for any anomalies.

During the examination, a smear is taken from the cervix and cervical os and analyzed for changes in the laboratory.

For deep infiltrating endometriosis diagnosis, rectovaginal palpation is pivotal. This involves using a finger to palpate the vagina and rectum for endometriosis lesions within the pelvis.


Ultrasound is another diagnostic tool. Vaginal or abdominal ultrasound can detect larger endometriosis lesions or growths based on their location. If ultrasound detects alterations, further examinations are usually recommended.

However, it is more likely to detect deep infiltrating lesions, endometriosis cysts, or extensive adenomyosis.

Superficial endometriosis lesions on the peritoneum are not visible on ultrasound, but they can lead to significant pain.

Abdominal Endoscopy (Laparoscopy)

Endometriosis is definitively diagnosed via laparoscopy, during which an endoscope is inserted through a small abdominal incision to locate the benign growths. Tissue samples are collected during the procedure and examined in the laboratory. Endometriosis is conclusively confirmed through laboratory analysis and the detection of endometrial cells.

Further Diagnostic Options

Additional diagnostic methods can offer insights into the extent, affected organs, or rule out alternative causes.

Challenges in Diagnosis

Because symptoms vary widely among affected women, endometriosis is often identified late. On average, reaching a definitive diagnosis can take up to 10 years.

Typically, diagnostic procedures are only pursued if symptoms persist for a significant time, are particularly severe, or if fertility is compromised.

Gynecological examinations and ultrasound imaging might not definitively confirm a diagnosis. In such cases, abdominal endoscopy (laparoscopy) is frequently necessary.

Treatment Options

The necessity and extent of endometriosis treatment depend on symptoms and their impact on the individual’s life.

If endometriosis does not impair a woman and she has completed family planning, treatment might not be required. Unfortunately, this scenario is rare. If endometriosis contributes to infertility or causes pain, various treatment avenues are available, tailored to the individual’s situation, often involving multiple components [1-5].

Treatment options include:

Initial therapy usually involves surgical removal via laparoscopy in symptomatic patients.

As an alternative or postoperative measure to prevent recurrence, hormone therapy, typically with progestogens, might be considered.

However, surgical intervention does not guarantee lifelong symptom relief. In around 40-50% of cases, endometriosis lesions reappear within 5 years post-surgery [5].


  1. Kiechle M, editor. Gynäkologie und Geburtshilfe: mit 325 Abbildungen und über 237 Tabellen. 2., überarbeitete Auflage. München: Elsevier, Urban & Fischer; 2011. 577 p.
  2. Kim JH, Han E. Endometriosis and Female Pelvic Pain. Semin Reprod Med [Internet]. 2018 [cited 2020 Apr 27];36(02):143–51. Available from: https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0038-1676103
  3. Peet D, Wilkening W. Endometriosezentrum Berlin [Internet]. Was ist Endometriose? 2020. Available from: https://www.fertilitaet.de/endometriosezentrum-berlin/was-ist-endometriose/
  4. Endometriose – gesundheitsinformation.de [Internet]. [cited 2020 Apr 28]. Available from: https://www.gesundheitsinformation.de/endometriose.2474.de.html
  5. Recurrence of endometriosis and its control. Available from: Guo SW. Recurrence of endometriosis and its control. Hum Reprod Update. 2009;15(4):441–461. doi:10.1093/humupd/dmp007
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