Endometriosis - clinical fact sheet and MCQ

Overview

Endometriosis is a chronic, inflammatory gynaecological condition characterised by the presence of endometrial-like tissue outside the uterus. It affects approximately 1 in 7 women in Australia, with an estimated global prevalence of 190 million individuals. 

Symptom severity varies widely, ranging from minimal discomfort to debilitating pelvic pain. The condition is associated with significant diagnostic delays and recurrent symptoms, leading to impaired quality of life and high economic burden. 

Endometriosis is commonly underdiagnosed or misdiagnosed. Historically, laparoscopic visualisation and histopathology were required for diagnosis, but advances in imaging have enabled non-invasive diagnostic approaches in many cases. 

Endometriosis is distinct from but often co-occurs with adenomyosis (the presence of endometrial-like tissue that  grows into the myometrium), although both are oestrogen-dependent conditions.

The image below summarises the diagnosis and management of endometriosis.

Image 1: diagnosis and management of endometriosis (source: RANZCOG living evidence guidelines, pg 28)

Diagnosis of endometriosis

1. Clinical history and examination 

Take a detailed menstrual, gynaecological, medical, and family history. 

Common symptoms (present in 25–70%): 

• severe dysmenorrhoe
• adyspareunia
• infertility
• chronic pelvic pain
• heavy menstrual bleeding

Less common symptoms (present in 10–25%): 

• bowel disturbance
• fatigue
• back pain
• sleep disturbance
• urinary symptoms
• headaches

The features of endometriosis may overlap with adenomyosis and the two conditions may co-occur. However, adenomyosis will more commonly present with heavy menstrual bleeding and dysmenorrhoea due to the growth of endometrial-like tissue into the myometrium with fewer of the systemic features seen in endometriosis.

Endometriosis may be subclassified by anatomical location into:

1. superficial peritoneal endometriosis (15-50% of all endometriosis cases): lesions form on the peritoneum
2. ovarian endometriosis (2-10% of women of childbearing age): ‘chocolate’ fluid-filled ovarian cysts (endometrioma) covered by endometrial epithelium
3. deep infiltrating endometriosis (2% of endometriosis cases): specific histological characteristics combined with infiltration of the pelvic organs, abdominal wall, and retroperitoneal structures

2. Clinical examination

Offer an abdominal and pelvic examination where appropriate. A normal examination does not exclude the diagnosis. Findings suggestive of endometriosis may include:

• reduced pelvic organ mobility
• pelvic tenderness
• nodularity of the posterior vaginal wall
• visible vaginal lesions

3. Investigations

• First-line imaging: transvaginal ultrasound (TVUS) is recommended for all symptomatic individuals, even if the examination is normal
• Alternative imaging: if TVUS is not appropriate (eg, if not sexually active or history of sexual trauma), consider a transabdominal ultrasound or pelvic MRI
  • MRI is preferred when deep endometriosis (such as involvement of the bowel, bladder, or ureter) is suspected or for surgical planning
  • non-invasive ultrasound and MRI may also aid diagnosis of adenomyosis
• Further evaluation: if symptoms persist despite empirical treatment or imaging is inconclusive, referral for specialist imaging or diagnostic laparoscopy may be appropriate
• Serum CA125: although it may be raised in endometriosis, it is not recommended for diagnostic use due to limited specificity and sensitivity

4. Differential diagnoses of endometriosis

 Consider other causes of pelvic pain such as:

• irritable bowel syndrome (pain is not usually cyclical; often diet-related and symptoms improve with bowel movements)
• interstitial cystitis (pain worsens with bladder filling; relief after voiding)
• pelvic floor dysfunction (pain localised to pelvic floor; worsens with palpation)
• pelvic inflammatory disease (often acute, with fever, discharge, and cervical motion tenderness)
• malignancy (including cancer of the bladder, colon, ovaries, urethra, and uterus)
• adenomyosis (more likely to present with dysmenorrhoea and heavy bleeding; systemic features less prominent)

5. Red flags prompting urgent referral:

• severe, persistent, or rapidly worsening symptoms
• unintended weight loss
• postcoital or intermenstrual bleeding that is persistent, or with cervical abnormalities noted on investigation
• suspicion of malignancy 

Management of endometriosis in primary practice

Encourage multidisciplinary, coordinated care involving GPs, gynaecologists, allied health professionals, pain specialists, and mental health providers. For rural and remote patients, telehealth and imaging access should be prioritised to ensure equity of care.

1. Initial management

• Hormonal therapy: first-line options include combined oral contraceptives and progestogens (oral, injectable, implant, or IUD)
  • trial for 3 months then review for efficacy and tolerability

Table 1: summary of hormonal treatments for endometriosis (source: RANZCOG living evidence guidelines, pg 70)

• Analgesia: NSAIDs, with or without paracetamol, may be trialled for pain relief for dysmenorrhoea
  • opioids should be avoided where possible
• Adjunct therapies: consider referral for physiotherapy, particularly pelvic floor therapy, and offer psychological support for persistent pain

Hormonal therapy is not recommended for patients trying to conceive as it does not improve spontaneous conception rates. Refer to a fertility specialist in these cases.

2. Escalation of treatment

• If symptoms persist after 3–6 months of first-line treatment, offer an alternative hormonal agent or refer for second-line therapies such as GnRH agonists or antagonists
• Consider add-back therapy: the use of low-dose hormonal therapy alongside GnRH agonists or antagonists to prevent bone loss and reduce their hypoestrogenic side effects without compromising the effectiveness of the treatment. Options typically include progesterone monotherapy, tibolone and testosterone, HRT, or selective oestrogen receptor modulators

3. Indications for referral

Referral to a specialist should be considered in the following scenarios:

• patients with suspected deep endometriosis (eg, dyspareunia, bowel symptoms, urinary symptoms)
• endometrioma identified on imaging
• persistent or severe symptoms unresponsive to first-line treatments
• ongoing fertility concerns
• adolescents - consider referring to a specialist with experience in adolescent gynaecology
  • hormonal treatments, including intrauterine devices, are safe and effective in this group

 4. Surgical management of endometriosis:

• laparoscopic ablation or excision may be indicated for diagnosis and treatment in individuals with refractory symptoms and may reduce the risk of recurrence for painful periods and dyspareunia
• surgical management is also likely to improve the rate of viable uterine pregnancy in women with superficial peritoneal endometriosis
• excision of endometriomas is preferred over cauterisation/ablation due to lower recurrence rates
• post-operative hormonal therapy (combined oral contraceptive, progestogens, GnRH agonists) is advised to reduce pain and recurrence, unless fertility is an immediate goal
• hysterectomy, which should include excision of visible lesions, may be considered for persistent symptoms unresponsive to other treatments. Patients should be counselled that it may not resolve all symptoms.
  • As endometriosis is considered an oestrogen-dependent disease, some may prefer to also have their ovaries removed (oophorectomy) during hysterectomy. This decision often depends on the severity and location of endometriosis, and should also consider associated long-term risks of inducing  menopause such as cardiovascular and bone disease
  • The clinical effectiveness of oophorectomy compared to hysterectomy alone remains unclear

5. Cancer risk from endometriosis

Patients should be reassured that while there is a slightly increased risk of ovarian and endometrial cancer, the absolute risk remains low, and they may in fact have a reduced risk of cervical cancer. As there is no screening test which can accurately detect early ovarian or endometrial cancer, there is no recommended additional testing for people with endometriosis aside from routine cervical screening as per population guidelines. 

References

1. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Australian Living Evidence Guideline: Endometriosis. Melbourne: RANZCOG; 2025. Available from: https://ranzcog.edu.au/resources/endometriosis-clinical-practice-guideline/. (last accessed May 2025).
2. Imperiale L, Nisolle M, Noël JC, Fastrez M. Three Types of Endometriosis: Pathogenesis, Diagnosis and Treatment. State of the Art. J Clin Med. 2023;12(3):994
3. Medscape. Chronic Pelvic Pain in Women Differential Diagnoses. 2025. Available at: https://emedicine.medscape.com/article/258334-differential. (last accessed June 2025).
4. Gunther R, Walker C. Adenomyosis. [Updated 2023 Jun 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539868/. (last accessed June 2025).
   
   
   

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