ESHRE Logo ESHRE Guideline for the Diagnosis and Treatment of Endometriosis


Establishing the diagnosis of endometriosis on the basis of symptoms alone can be difficullt because the presentation is so variable and there is considerable overlap with other conditions such as irritable bowel syndrome and pelvic inflammatory disease. As a result there is often a delay of up to 12 years between symptom onset and a definitive diagnosis (Arruda et al., 2003; Hadfield et al., 1996; Husby et al., 2003).

The following symptoms can be caused by endometriosis based on clinical and patient experience:

  • severe dysmenorrhoea;
  • deep dyspareunia;
  • chronic pelvic pain;
  • ovulation pain;
  • cyclical or perimenstrual symptoms (e.g. bowel or bladder associated) with or without abnormal bleeding;
  • infertility;
  • chronic fatigue.

However, the predictive value of any one symptom or set of symptoms remains uncertain as each of these symptoms can have other causes, and a significant proportion of affected women are asymptomatic.

Clinical signs

Finding pelvic tenderness, a fixed retroverted uterus, tender utero-sacral ligaments or enlarged ovaries on examination is suggestive of endometriosis. The diagnosis is more certain if deeply infiltrating nodules are found on the utero-sacral ligaments or in the pouch of Douglas, and/or visible lesions are seen in the vagina or on the cervix. The findings may, however, be normal.

Deeply infiltrating nodules are most reliably detected when clinical examination is performed during menstruation (Koninckx et al., 1996).

Level 3

Supporting Documentation




This guideline, which is reviewed annually, was last updated on 30 June 2007

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