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For further information, see CMDT Part 18-05: Pelvic Pain

Key Features

Essentials of Diagnosis

  • Dysmenorrhea

  • Dyspareunia

  • Infertility (increased frequency)

  • Abnormal uterine bleeding

General Considerations

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

  • Its causes, pathogenesis, and natural course are poorly understood

  • It is associated with an increased risk of coronary heart disease


  • 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 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 (PID)

  • 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

  • Progestins, specifically oral norethindrone acetate and subcutaneous depot medroxyprogesterone acetate (DMPA), 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, and it is recommended before surgery

  • Low-dose oral contraceptives can be given cyclically or continuously; prolonged suppression of ovulation will often inhibit further stimulation of residual endometriosis, especially if taken after one of the therapies mentioned here

  • Any of the combination oral contraceptives, the contraceptive patch, or the vaginal ring

    • May be used continuously for 6–12 months

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

  • The optimum duration of therapy is not known

  • 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 in the lowest dose necessary to suppress menstruation, usually 200–400 ...

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