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For further information, see CMDT Part 18-05: Endometriosis

Key Features

Essentials of Diagnosis

  • Dysmenorrhea or pelvic pain

  • Dyspareunia

  • Infertility (increased frequency)

General Considerations

  • An aberrant growth of endometrium outside the uterus, particularly in the dependent parts of the pelvis and in the ovaries

  • While retrograde menstruation is the most widely accepted cause, its causes, pathogenesis, and natural course are not fully understood

  • Principal manifestations are chronic pain and infertility


  • The overall prevalence in the United States is 6–10%

Clinical Findings

Symptoms and Signs

  • Dysmenorrhea, chronic pelvic pain, and dyspareunia, are among the well-recognized manifestations

  • A significant number of women with endometriosis, however, remain asymptomatic

  • Pelvic examination

    • Normal in most women

    • However, can disclose

      • Tender nodules in the cul-de-sac or rectovaginal septum

      • Uterine retroversion with decreased uterine mobility

      • Uterine tenderness

      • Adnexal mass or tenderness

Differential Diagnosis

  • Pelvic inflammatory disease

  • Ovarian neoplasms

  • Uterine myomas

  • Bowel neoplasm


Imaging Studies

  • Imaging is useful mainly in the presence of a pelvic or adnexal mass

  • Transvaginal ultrasonography is the imaging modality of choice to detect the presence of deeply penetrating endometriosis of the rectum or rectovaginal septum

  • MRI should be reserved for equivocal cases of rectovaginal or bladder endometriosis

Diagnostic Procedures

  • Ultimately, a definitive diagnosis of endometriosis is made only by histology of lesions removed at surgery



  • Nonsteroidal anti-inflammatory drugs may be helpful

  • Estrogen-progestin contraceptives

    • First-line treatment

    • Can be given cyclically or continuously

    • Prolonged suppression of ovulation often inhibits further stimulation of residual endometriosis

    • Any of the combination oral contraceptives, the contraceptive patch, or the vaginal ring may be used continuously

    • Breakthrough bleeding can be treated with conjugated estrogens, 1.25 mg orally daily for 1 week, or estradiol, 2 mg daily orally for 1 week

    • Alternatively, a short hormone-free interval to allow a withdrawal bleed can be utilized whenever bothersome breakthrough bleeding occurs

  • Progestins, specifically the oral norethindrone acetate, the subcutaneous depot medroxyprogesterone acetate (DMPA), and the etonogestrel implant, have been approved by the US Food and Drug Administration (FDA) for treatment of endometriosis-associated pain

  • Intrauterine progestin with the levonorgestrel intrauterine system

    • Has also been shown to be effective in reducing endometriosis-associated pelvic pain

    • Is recommended before surgery

  • Gonadotropin-releasing hormone analogs

    • Nafarelin nasal spray, 0.2–0.4 mg twice daily, or long-acting injectable leuprolide acetate, 3.75 mg monthly intramuscularly, used for 6 months, suppress ovulation

    • Side effects consisting of vasomotor symptoms and bone demineralization may be relieved by "add-back" therapy with conjugated equine estrogen, 0.625 mg or norethindrone, 5 mg daily orally

  • Danazol

    • Used for 4–6 months ...

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